Search

Background: Distal metatarsal osteotomy has been used to alleviate plantar pressure caused by anatomic deformities. This study’s purpose was to examine the effect of minimally invasive floating metatarsal osteotomy on plantar pressure in patients with diabetic metatarsal head ulcers. Methods: We performed a retrospective case series of prospectively collected data on 32 patients with diabetes complicated by plantar metatarsal head ulcers without ischemia. Peak plantar pressure and pressure time integrals were examined using the Tekscan MatScan prior to surgery and 6 months following minimally invasive floating metatarsal osteotomy. Patients were followed for complications for at least 1 year. Results: Peak plantar pressure at the level of the osteotomized metatarsal head decreased from 338.1 to 225.4 kPa ( P < .0001). The pressure time integral decreased from 82.4 to 65.0 kPa·s ( P < .0001). All ulcers healed within a mean of 3.7 ± 4.2 weeks. There was 1 recurrence (under a hypertrophic callus of the osteotomy) during a median follow-up of 18.3 months (range, 12.2-27). Following surgery, adjacent sites showed increased plantar pressure and 4 patients developed transfer lesions (under an adjacent metatarsal head); all were managed successfully. There was 1 serious adverse event related to surgery (operative site infection) that resolved with antibiotics. Conclusion: This study showed that the minimally invasive floating metatarsal osteotomy successfully reduced local plantar pressure and that the method was safe and effective, both in treatment and prevention of recurrence. Level of Evidence: Level III, retrospective case series of prospectively collected data.

Minimally invasive floating metatarsal osteotomy is an option for treating neuropathic ulcers under the metatarsal heads. This study presents the radiographic results of the floating metatarsal osteotomy. We reviewed files and radiographs at least 4 months after a floating metatarsal osteotomy in patients with diabetic neuropathy. In 71 osteotomies in 54 patients with late onset diabetes (mean age 61 ± 9, mean HbA1c 7.9 ± 1.9%), the primary ulcer healed within 3.5 ± 1.4 weeks. Of 66 osteotomies where radiographs were available 10 had non-union (15%, all asymptomatic), 15 (23%) had hypertrophic callus formation and 41 (62%) had normal union. One patient developed an ulcer under the hypertrophic callus. This necessitated callus resection. Asymptomatic non-union may happen in 15% of floating osteotomies, but the osteotomies appear to be relatively safe and effective for neuropathic plantar metatarsal head ulcers. Hypertropic callus causing local re-ulceration is rare and can be managed surgically.

Background: Foot ulcers carry considerable morbidity in patients with peripheral neuropathy and frequently lead to foot amputation. The purpose of this study was to present our experience treating recalcitrant ulcers underlying the hallux interphalangeal joint in patients with diabetes mellitus (DM)–related neuropathy with a first metatarsophalangeal (MTPJ1) resection arthroplasty. Methods: We retrospectively reviewed the computerized medical files of patients with diabetic neuropathy treated with a MTPJ1 resection arthroplasty. We performed 28 arthroplasties on 20 patients with a mean age of 59 years. The patients had a diagnosis of DM for a mean of 10.7 years. Of the ulcers, 26 were grade 1A ulcers, and 2 were grade 2A ulcers (University of Texas score); the ulcer’s mean age was 5.4 months. The mean dorsiflexion of the hallux before surgery was 46 degrees. Results: The primary ulcer recovered in a mean of 3.1 weeks. Major complications (wound dehiscence and infection) occurred in 6 of 28 operations. Patients returned to normal activity 4 weeks after all procedures except in the 6 patients with dehiscence. In a subgroup of patients with follow-up longer than a year, the ulcer recurred after 4 of 18 arthroplasties (22%) between 3 and 12 months due to postoperative hallux rigidus. In the remaining 14 of 18 arthroplasties (78%), there was no recurrence during a mean follow-up of 26 months. Conclusion: MTPJ1 resection arthroplasty may be considered in a patient with resistant plantar hallux ulcerations, even in the absence of hallux rigidus. As with all operations on neuropathic feet in patients with DM, the surgeon and the patient should be aware that there is a significant likelihood of complications, but most are treatable. Level of Evidence: Level IV, case series.

Background: Whether the human Achilles tendon undergoes hypertrophic changes as measured by an increase in cross-sectional area, in response to endurance training exercise remains in question. We investigated the hypothesis that transition from civilian life through 6 months of elite infantry training would induce adaptive Achilles tendon hypertrophy. Methods: Seventy-two new elite infantry recruits had the cross-sectional area of their Achilles tendons measured at a point 2.5 cm proximal to the Achilles insertion by ultrasound before beginning elite infantry training. Measurements were repeated by the same ultrasonographer for those recruits who were still in the training program at 6 months. Prior to beginning the study the intraobserver reliability of the ultrasonographer’s Achilles tendon measurements was calculated (intraclass correlation coefficient = .96). Fifty-five recruits completed 6 months of training. Results: The mean cross-sectional area of their right Achilles tendon increased from 47.0 ± 11.2 to 50.2 ± 9.6 mm2 ( P = .037) and the left Achilles tendon from 47.2 ± 8.9 to 51.1 ± 8.3 mm2 ( P = .013). The change in cross-sectional area did not correlate with subject height, weight, prior sport history, or jumping and running abilities. Conclusions: An abrupt stimulus of 6 months of elite infantry training was adequate to induce hypertrophic changes in the Achilles tendon. This is the first human prospective study showing an increase in the Achilles tendon cross-sectional area in response to rigorous endurance type training. The finding supports the hypothesis that the Achilles tendon in response to sufficiently high and sustained loading can remodel its morphological properties and thereby strengthen itself. Level of Evidence: Level II, etiology study.

Background: Chronic exertional compartment syndrome can present either as anterolateral lower leg pain or as painful muscle herniation. If an athlete or a soldier wants to continue training, there is no proven effective nonoperative treatment, and fasciotomy of 1 or more of the lower leg muscle compartments is usually recommended. Our clinical protocol differs from most reported ones in the use of the forefoot rise test to increase pressure and provoke pain and our recommending minimal surgery of the anterior compartment only. We present results of surgery based on our clinical management flowchart. Methods: Patients who had surgery during a 12-year period were reviewed by telephone interview or office examination. Pain was graded from 0 (none) to 4 (unbearable). Preoperative resting and exercise anterior compartment pressures were evaluated in most subjects before and immediately following a repeated weight-bearing forefoot rise test. Surgery was under local anesthesia, limited to the anterior compartment only and percutaneous (excepting muscle hernias). There were 36 patients, mean age 24 years. Results: Of 16 patients who were originally operated unilaterally, 5 patients were later operated on the other side. Mean presurgery resting pressure was 56 mm Hg (40-80 mm Hg) rising to 87 mm Hg (55-150 mm Hg) with exercise. Mean exercise pain score dropped from 2.9 presurgery to 1.3 postsurgery (n = 35, P < .0001). Complications included superficial peroneal nerve injury (3 legs in 3 patients, 1 requiring reoperation). Conclusion: When we used our clinical management flowchart based on the forefoot rise test, percutaneous fasciotomy of the anterior compartment alone provided good clinical results. Care must be taken to prevent injury to the superficial peroneal nerve in the distal lower leg. Level of Evidence: Level IV, retrospective case series.

Background: Most previous studies on hallux valgus focused on the possible relationship between this deformity and muscles and/or ligaments in the foot and lower leg. Very little is known about the relationship between hallux valgus and alignment of the proximal joints. The aims of the present study were to determine the extent to which lower extremity alignment characteristics of the hip, knee, ankle, and foot were related to the manifestation of hallux valgus and to identify variables predicting its development in women. Methods: A group of 25 women with hallux valgus and 24 control women, age 51 to 80 years, were interviewed and screened for the current study. Measurements recorded were hallux valgus angle; intermetatarsal angle; a set of body physique measures (eg, height); range of motion at the hip, knee, ankle, and foot joints; general hypermobility; lower extremity alignment (eg, tibiofemoral angle); and 9 anatomical anomalies (eg, knee valgus/varum). Results: Women with hallux valgus manifested notably higher range of motion at their joints, different lower extremity alignment, higher prevalence of general joint hypermobility, and higher prevalence of anatomical anomalies compared with controls. Estimated marginal means for most joint range of motion and lower extremity alignment measurements were notably higher for the hallux valgus group. Conclusion: Lower extremity alignment and joint range of motion were correlated with hallux valgus. Future studies could possibly identify anatomic risk factors for the development of hallux valgus, nonsurgical methods of prevention and adjunctive surgical methods of treatment. Level of Evidence: Level III, comparative case series.

Background: Foot orthoses are widely prescribed both to treat existing pathological conditions and to prevent overuse injuries, but little is known about the effect of their material composition and fabrication technique on patient comfort and the incidence of overuse injuries. Materials and Methods: The acceptance rates and comfort scores of soft custom, soft prefabricated, semirigid biomechanical, and semirigid prefabricated orthoses and their effect on the incidence of stress fractures, ankle sprains, and foot problems were studied in a prospective, randomized, single-blinded clinical trial among 874 infantry recruits during basic training. Results: A statistically significantly lower number of recruits given soft prefabricated orthoses (53%) finished basic training in their assigned devices than in the soft custom group (72%), in the semirigid biomechanical group (75%), and in the semirigid prefabricated group (82%) ( p = .003). For recruits who finished training in their assigned orthoses, the soft custom (3.54) and soft prefabricated (3.43) orthoses had significantly higher comfort scores than the semirigid biomechanical (3.23) and prefabricated (3.17) orthoses, ( p = .0001). There was no statistically significant difference in the incidence of stress fractures, ankle sprains, or foot problems between recruits using the different types of orthoses. Conclusions: These findings suggest that if a foot orthosis is being dispensed as prophylaxis for overuse injuries in an active, healthy population, there is little justification for prescribing semirigid biomechanical orthoses. Their cost is high compared to other types of orthoses, without an advantage in comfort or a reduction in stress fractures, ankle sprains, and foot problems.

In a prospective study of risk factors for Achilles tendinopathy among four induction cycles of infantry recruits, 95 out of 1405 recruits, (6.8%) were found to suffer from Achilles tendinopathy. In more than 94% of the cases, the tendinopathy was considered to be paratendinitis. Training season had a statistically significant effect on the incidence of Achilles paratendinitis with 3.6% suffering in the summer and 9.4% in the winter ( p = .001). This increased risk for Achilles paratendinitis in cold weather outdoor training can be explained by a fall in temperature of the Achilles paratenon whose membranes are rich in mucopolysaccharides and serve as a lubricant for gliding of the tendon and epitenon. Decreased temperature may increase the viscosity of the lubricant and thereby increases friction and risk for Achilles paratendinitis. This same relationship illustrates why “warming up” before exercising may be important in lowering the incidence of Achilles paratendinitis.

Human in vivo tibial strains during vigorous walking have not been found to exceed 1200 microstrains. These values are below those found in ex vivo studies (>3000 microstrains) to cause cortical bone fatigue failure, suggesting that an intermediate bone remodeling response may be associated with tibial stress fractures. Metatarsal stress fractures, however, often develop before there is time for such a response to occur. Simultaneous in vivo axial strains were measured at the mid diaphysis of the second metatarsal and the tibia in two subjects. Peak axial metatarsal compression strains and strain rates were significantly higher than those of the tibia during treadmill walking and jogging both barefoot and with running shoes and during simple calisthenics. During barefoot treadmill walking metatarsal compression strains were greater than 2500 microstrains. During one- and two-leg vertical jumps and broad jumping, both metatarsal compression and tension strains were >3000 microstrains. Compression and tension strains in the metatarsus unlike those of the tibia may be sufficiently high even during moderate exertional activities to cause fatigue failure of bone secondary to the number of loading cycles without an intermediate bone remodeling response.

To test the hypothesis that shoe sole composition can affect the level of bone strain and strain rates that contribute to the development of stress fractures, in vivo tibial strain measurements were made during treadmill walking while wearing four shoes which differed only in their sole composition. Soles of 65 Shore A polyurethane with an embedded heel air cell had significantly lower compression and shear strains and shear strain rates than soles of 65, 75 and a composite of 40/65 Shore A polyurethane with no embedded air cells. A sole composed of 65 Shore A polyurethane with an embedded air cell can potentially be protective against stress fracture in a walking shoe.