The plantar plate is a rarely seen, yet central structure to the lesser metatarsal phalangeal (MP) joint. Thirty cadaver lesser MP joints were studied to obtain a detailed description of the plate, including its dimensions, connections, and histology. The plate was found to be made of fibrocartilage with fiber orientation which suggests that it withstands tensile loads in line with the plantar fascia as well as the compressive loads from the metatarsal head. The plantar plate was the most substantial distal insertion of the plantar fascia. Impressive plantar plate attachments were noted to the proximal phalanx, the major longitudinal bands of the plantar fascia, and the collateral ligaments. The plate and collateral ligaments formed a substantial soft tissue box connected to the sides of the metatarsal head. From the dissections, it is apparent that malposition of the toe at the MP joint is likely over time to be associated with pathology in both the collateral ligaments and the plate. Because of these attachments and a close association with the flexor tendons to the lesser toe, the plate can be compared with the sesamoid mechanism of the first MP joint.
Category: Ankle, Arthroscopy, Sports Introduction/Purpose: Historically, microfracture has been the standard surgical treatment for talar osteochondral lesions (OLTs); however, it is associated with unsatisfactory long-term results due to the formation of biomechanically inferior reparative fibrocartilage as opposed to normal hyaline-like cartilage. Thus, the optimal treatment for OLTs remains contested. Application of micronized allogenic cartilage extracellular matrix (ECM) as an adjuvant therapy during the treatment of OLTs offers a promising option that could be administered arthroscopically to improve the quality of reparative tissue. The purpose of this study is to provide a case-control series comparing radiographic and functional outcomes following treatment of OLTs with an adjuvant mixture of micronized allogenic cartilage ECM and bone marrow aspirate concentrate (BMAC) to those achieved following standard microfracture with or without BMAC. Methods: 194 patients (average age 37) with a minimum 1-year follow-up who were treated for an OLT by a fellowship-trained foot and ankle surgeon were screened for inclusion. 107 patients who received mixed micronized cartilage ECM and BMAC (Group I), 40 who were treated by microfracture augmented with BMAC (Group II), and 47 patients who were treated with traditional microfracture alone (Group III) were identified. Preoperative lesion size, lesion location, and concurrent injuries were recorded retrospectively. Foot and Ankle Outcome Scores (FAOS) were completed preoperatively and postoperatively through the prospective Registry database at the authors’ institution. Outcomes were assessed radiographically at a minimum of 6 months postoperatively by a trained radiologist using the MOCART scoring system. Linear regression modeling was used to assess differences in MOCART scores, post-operative FAOS scores, pre-to-postoperative change in FAOS, and the rate of revision surgery between groups I, II, and III. Results: The average MOCART score for Group I was 62.39, (average follow-up 16.13 months; n = 46), 58.8 (26.82 months; n =25) for Group II and, 55.36 (43.12 months; n=14) for Group III patients (p=0.57). The rate of revision surgery for OLTs treated using adjuvant micronized cartilage ECM was 5% and was significantly lower when compared to a 22.7% rate of revision surgery following microfracture with or without BMAC (p<0.001). Finally, when controlling for lesion size, changes in pre-to-postoperative FAOS Pain and Sports Activities were significantly different amongst the 3 treatment groups (p=0.05). Group I had the greatest improvement in Pain. Conclusion: Micronized allogenic cartilage extracellular matrix serves as an adjunctive therapy that may help improve patients’ radiographic and functional outcomes following treatment of OLTs when compared to outcomes following traditional microfracture. Specifically, use of adjunctive ECM appears to have better postop FAOS Pain scores when controlled for lesion size when compared to microfracture. There is a lower rate of revision surgery with the use of allogenic cartilage ECM in the short to intermediate term when compared with microfracture.
While metatarsus primus elevatus (MPE) has been implicated in the development of hallux rigidus, previous studies have presented conflicting findings regarding the relationship between MPE and arthritis. This may be due to the variety of definitions for MPE and the radiographic measurement techniques that are used to assess it. Additionally, previous studies have only assessed elevation of the first metatarsal with respect to the floor or the second metatarsal, and not with respect to the proximal phalanx. The aim of this study was to examine the reliability of new radiographic measurements that consider the elevation of the first metatarsal in relation to the proximal phalanx, rather than in relation to the second metatarsal as previously described, to assess for MPE. In addition, we aimed to determine whether the elevation of the first metatarsal was significantly different in patients with hallux rigidus than in a control population.A retrospective chart review was conducted from prospectively collected registry data at the investigators' institution to identify patients with hallux rigidus (n = 65). A size-matched control cohort of patients without evidence for first metatarsophalangeal (MTP) joint arthritis was identified (n = 65). Patients with a previous history of foot surgery, rheumatoid arthritis, or hallux valgus were excluded. Five blinded raters of varying levels of training, including 2 research assistants, 1 senior orthopedic resident, 1 foot and ankle fellowship-trained orthopedic surgeon, and 1 attending musculoskeletal fellowship-trained radiologist, evaluated 7 radiographic measurements for their reliability in assessing for MPE in hallux rigidus and control groups. Four of the 7 were newly designed measurements that include the relationship of the first MTP joint. Inter- and intrarater reliability were calculated using intraclass correlation coefficients (ICCs) and categorized by Landis and Koch reliability thresholds. The measurements between the hallux rigidus and control populations were compared using an independent t test.Six of the 7 radiographic measurements were found to have substantial to almost perfect interrater reliability (ICC, 0.800-0.953) between all levels of training, except for the proximal phalanx-first metatarsal angle, which showed moderate reliability (ICC, 0.527). Substantial to almost perfect intrarater reliability (ICC, 0.710-0.982) was demonstrated by the measurements performed by research assistants. All 7 of the measurements taken by the musculoskeletal fellowship-trained radiologist demonstrated significant differences in first metatarsal elevation between the hallux rigidus and control populations, with the hallux rigidus group showing increased elevation (P < .001-.019).This study confirmed the reliability of 7 radiographic measurements used to assess for MPE, including 3 previously established and 4 newly described measurements. Observers across all levels of training were able to demonstrate reliable measurements. In addition, the measurements were used to show that patients with hallux rigidus were more likely to have MPE compared with patients without radiographic evidence for first MTP arthritis. These measurements could be used in future work to examine how the presence of MPE relates to the etiology and progression of hallux rigidus, and how it affects the results of operative treatment.Level III, retrospective comparative study.
In the treatment of progressive collapsing foot deformity (PCFD), the combination of bone shape, soft tissue failure, and host factors create a complex algorithm that may confound choices for operative treatment. Realignment and balancing are primary goals. There was consensus that preservation of joint motion is preferred when possible. This choice needs to be balanced with the need for performing joint-sacrificing procedures such as fusions to obtain and maintain correction. In addition, a patient's age and health status such as body mass index is important to consider. Although preservation of motion is important, it is secondary to a stable and properly aligned foot.Level V, consensus, expert opinion.
Establishing a surgical plan for ankle deformities necessitates a comprehensive understanding of the deforming forces involved, and the morphology of the ankle deformity plays an important role as well. Valgus tibiotalar tilt development has mostly been described in patients with a low medial longitudinal arch, as seen in progressive collapsing foot deformity (PCFD). However, some valgus ankles demonstrate no radiographic evidence of a collapsed medial arch. This study aims to investigate whether there are differences in the radiographic morphology of valgus ankle deformities between patients with and without a low medial longitudinal arch to explore if they have different etiologies.
There are many surgical techniques described for the deltoid ligament and spring ligament reconstruction in the treatment of a collapsing flatfoot. In some cases, addressing these ligaments may offer a way to treat a collapsing flatfoot that preserves the talonavicular and subtalar joints. Preservation of these joints may lead to better outcomes for patients, as their functionality is not limited by hindfoot fusions. Preliminary evidence suggests that patients, when properly selected for, show good long-term outcomes after undergoing surgical reconstruction of those ligaments. The technique for spring ligament and deltoid ligament reconstruction in cases of collapsing flatfoot deformity is described in this article. Level of Evidence: Diagnostic Level V—Expert Opinion. See Instructions for Authors for a complete description of levels of evidence.
Anterior tibial tendon ruptures are rare, and most studies have reported subjective outcome data, with little or no objective analysis. The purpose of this study was to review the results of the operative treatment of anterior tibial tendon ruptures using the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale and objective isokinetic testing.We retrospectively reviewed the results of operatively treated anterior tibial tendon ruptures in 10 patients. The average age at the time of surgery was 57 (18 to 79) years. The etiology of rupture was traumatic in five and spontaneous in five patients. Evaluation consisted of preoperative and postoperative questionnaires, physical examination, and isokinetic strength testing. Average time between surgery and isokinetic testing was 27.9 months.The average AOFAS score was 71.9 preoperatively and 89.8 postoperatively. Eight of 10 patients reported improvement in pain, and nine of 10 patients reported increased activity level postoperatively. All patients were satisfied with the overall function of their foot and would undergo the procedure again. The peak torque generated in the operative extremity during ankle dorsiflexion and hindfoot inversion was less than that of the uninvolved extremity. No statistically significant difference was noted between peak torque generation in ankles treated with direct anterior tibial tendon repair and ankles treated with anterior tibial tendon repair with augmentation.Operative treatment of anterior tibial tendon rupture resulted in a high level of patient satisfaction; however, isokinetic testing demonstrated a decrease in dorsiflexion and inversion strength compared to the uninjured extremity. The clinical significance of this residual weakness was not apparent in most patients. Patients with anterior tibial tendon ruptures should be forewarned that normal strength may not be a realistic expectation after surgery.
Background: Procedures utilized to address the flatfoot in this study included medializing calcaneal osteotomy, posterior tibial tendon reconstruction with flexor digitorum longus tendon transfer, and in patients with more severe deformity, lateral column lengthening. We evaluated patients age 50 and less at the time of surgery, who underwent surgical reconstruction for Stage 2 posterior tibial tendon dysfunction. Pre- and postoperative activity levels were evaluated to assess the effect of surgical reconstruction in the younger patient. Materials and Method: Thirty-four feet in 30 patients (11 male, 19 female) with an average age of 41.2 (range, 17 to 50) years had surgery between 1997 and 2004. All feet were examined at an average followup of 44.5 (range, 24 to 65) months and were evaluated with the American-Orthopaedic-Foot and Ankle Society (AOFAS) Hindfoot-Score and SF-36 score. Results: The average preoperative AOFAS-Score was 53.1 ± 14.5 points and 83.2 ± 12.2 points at final postoperative followup. The mean improvement was 29.5. The difference between the preoperative and postoperative AOFAS score was significant ( p < 0.0001) using a two-tailed t-test. The difference in the AOFAS pain and alignment subscales was also significant ( p < 0.0001). The function subscale improvement was also significant ( p = 0.018). The mean physical function component of the postoperative SF-36 score was 79.2. A correlation was found between the SF-36 physical component score and the post operative AOFAS score ( r 2 = 0.754). Conclusion: While some lateral discomfort or pain occurred in patients with or without a lateral column lengthening, the posterior tibial tendon reconstruction utilizing medial calcaneal displacement osteotomy with flexor digitorum longus transfer and a lateral column lengthening with more deformity was successful in the higher-functioning, younger patients.
Lateral column lengthening is used to correct abduction deformity at the midfoot and improve talar head coverage in patients with flatfoot deformity. It was our hypothesis that following a stepcut lengthening calcaneal osteotomy (SLCO), patients would have adequate correction of the deformity, a high union rate of the osteotomy, and improvement in clinical outcome scores.We retrospectively reviewed 37 consecutive patients who underwent SLCO for the treatment of stage IIB flatfoot deformity with a minimum 2-year follow-up. Deformity correction was assessed using preoperative and postoperative weight-bearing radiographs. Healing of the osteotomy was assessed by computed tomography. Clinical outcomes included the FAOS and SF-36 questionnaires. The Wilcoxon signed-rank test was used to compare clinical outcome scores. An alpha level of .05 was deemed statistically significant.Healing of the osteotomy occurred at a mean of 7.7 weeks postoperatively. The talonavicular (TN) coverage angle improved from 34.0 to 8.8 (P < .001), the percentage of TN uncoverage improved from 40.9% to 17.7% (P < .001), and the TN incongruency angle improved from 68.1 to 8.7 (P < .001). In addition, there was an improvement in FAOS pain (P < .001), daily activities (P < .001), sport activities (P = .006), and quality of life scores (P < .001). Overall SF-36 scores also showed improvement postoperatively (P < .001). There was no incidence of delayed union, nonunion, or graft collapse.Following SLCO, patients demonstrated excellent healing, good correction of the deformity, and improvement in clinical outcomes scores. The SLCO is an alternative to the Evans osteotomy for lateral column lengthening.Level IV, retrospective case review.
Background: Restoring the joint line is an important principle in total knee arthroplasty. However, the effect of joint line level on patient outcomes after total ankle arthroplasty (TAA) remains unclear, as there is no established method for measuring ankle joint level in TAA. The objective of this study was to develop a reliable radiographic ankle joint line measurement method and to compare ankle joint line level measured pre-TAA, post-TAA, and in nonarthritic ankles. Methods: A total of 112 radiographic sets were analyzed. Each set included weightbearing anteroposterior radiographs of the operative ankle taken preoperatively, 1-year postoperatively, and of the contralateral ankle. Measurements of vertical intermalleolar distance (VIMD) and vertical joint line distance (VJLD) at pre-TAA, post-TAA, and of the contralateral ankle were recorded by 2 authors on 2 separate occasions. The ratio of VJLD to VIMD was defined as the joint line height ratio (JLHR). Reliability of measurements and correlation between VIMD and VJLD were assessed. Pre-TAA, nonarthritic contralateral ankle, and post-TAA JLHR were compared and considered significantly different if P <.05. Results: The inter- and intrarater reliability of radiographic measurements was excellent ( r > 0.9). There were strong positive correlations of VIMD and VJLD, r = 0.809 (pre-TAA)/0.756 (post-TAA), P < .001. Mean (SD) pre-TAA, nonarthritic contralateral ankle, and post-TAA JLHRs were 1.54 (0.31), 1.39 (0.26), and 1.62 (0.49), respectively. Pre- and post-TAA JLHRs were significantly higher compared to the nonarthritic contralateral ankle ( P < .05). JHLR was not significantly different between pre- and post-TAA ( P = .15). Conclusion: The JLHR was reliable and could be a clinically applicable method for assessing ankle joint line level in patients undergoing TAA. End-stage ankle arthritis demonstrated elevated joint line level compared with nonarthritic ankles, and the joint line level post-TAA remained elevated compared with nonarthritic ankles. Further studies are needed to understand the effect of joint line elevation on clinical outcomes after TAA. Level of Evidence: Level III, retrospective comparative study.
