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Background: Symptomatic flexible flatfoot causes alterations in gait, but exactly how this condition affects the intersegmental motion of the foot during the gait cycle remains unclear. Previous studies have examined the kinematics, yielding inconsistent findings. Therefore, the objective of this study was to investigate how flexible flatfoot deformity, defined as Johnson and Strom classification staging II, affects the intersegmental motion of the foot during fast walking based on a comparison with the matched control group. Methods: Eleven participants with symptomatic flexible flatfoot and 11 healthy matched control participants were recruited using a foot screening protocol incorporated through a foot physical examinations and radiographic measurements. All demographic characteristics exhibited comparable profiles between the groups. During controlled walking, kinematic outcomes pertaining to the hallux, hindfoot, forefoot, and tibia were collected using the multisegmental Oxford Foot Model. Results: All spatiotemporal parameters were comparable between the groups. In comparison to the control group, individuals with symptomatic flexible flatfoot demonstrated increased hallux valgus and plantarflexion, increased forefoot abduction, heightened hindfoot eversion, and internal rotation. Notably, no significant major differences were observed in the tibia motion segment. Further, significant correlations were identified between static foot measurements and the extent of the maximum deviation observed during dynamic kinematic assessments. Conclusion: Compared with age- and gender-matched controls, participants with symptomatic flexible flatfoot exhibited significant gait pattern deviations. A significant correlation also exists between static foot deformity measurements and dynamic kinematic deviations. Collectively, these findings have implications for developing targeted therapeutic interventions to address flexible flatfoot. [ABSTRACT FROM AUTHOR]

Background: Combining osteotomies and soft tissue procedures is believed to reduce sesamoids in their anatomical position and maintain long-term correction when treating hallux valgus deformity. This study determines if a radiologic association exists between a radiolucent sign and a full percutaneous adductor tendon release (PATR), including a cadaveric study and a consecutive case series. Another aim was to determine the intra- and interobserver reliability of these observations. Methods: A prospective observational study was made between 2018 and 2019. First, a PATR was done on cadaveric specimens and, after the procedures, dissected to correlate what was seen fluoroscopically. The clinical group included 39 feet that presented mild-to-moderate HV deformity and were treated with percutaneous osteotomies associated with PATR. Results: Observers 1 and 2 saw a radioscopic radiolucent sign in 100% of cadavers and the patient population. They also observed a triangle-shaped image with an incidence of 75%, which we have named the "triangle sign." Conclusion: The triangle sign may be helpful in the intraoperative confirmation of PATR and latero-plantar capsule release using this percutaneous technique. [ABSTRACT FROM AUTHOR]

Background: Recognizing preoperative first-ray hypermobility is important to planning hallux valgus (HV) surgery. A recent study showed the minimally invasive chevron Akin (MICA) osteotomy increased varus displacement of the proximal fragment of the first metatarsal osteotomy. The present study aims to evaluate the ability of the radiographic firstray squeeze test to predict the varus displacement of the proximal fragment of the first metatarsal osteotomy when performing the MICA procedure. Methods: A prospective case series of patients with moderate to severe HV who underwent MICA was performed. The HV deformity correction was analyzed by comparing the preoperative and 12-week postoperative hallux valgus angle (HVA) and the intermetatarsal angle between the first and second rays (1-2 IMA). The ability of the radiographic firstray squeeze test to predict the varus displacement of the first metatarsal was done by comparing the preoperative 1-2 IMA measured in the AP radiographic first-ray squeeze test (IMA-ST) with the intermetatarsal angle between the second metatarsal and the axis of the first metatarsal osteotomy proximal fragment (IAPF) taken 12 weeks postoperatively. Results: Between July 2022 and May 2023, a total of 39 feet in 28 patients underwent MICA. The mean IMA improved from 13.8 (SD = 2.2) to 3.8 degrees (SD = 1.5) (P < .001), and the mean HVA improved from 27.8 (SD = 6.1) to 4.9 degrees (SD = 2.5) (P < .001). A linear regression analysis revealed that IMA-ST is highly associated with the 12 week assessed IAPF (P < .001). Conclusion: The preoperative radiographic first-ray squeeze test appears to predict with high fidelity the varus displacement of the proximal fragment of the first metatarsal that can occur after the MICA procedure. [ABSTRACT FROM AUTHOR]

Background: The impact of pronation and sesamoid coverage on clinical outcomes following percutaneous hallux valgus surgery are not currently known. The aim of this study was to investigate if sesamoid coverage was associated with worse clinical outcomes at 12-month follow-up following percutaneous hallux valgus surgery. Methods: Retrospective comparative observational study of clinical and radiographic outcomes based on a previously published prospective dataset. Patients were stratified into 3 cohorts based on the degree of sesamoid coverage (normal, mild, or moderate) on 12-month weightbearing radiographs following fourth-generation percutaneous hallux valgus surgery. Primary outcome was a validated patient-reported outcome measure (PROM), the Manchester-Oxford Foot Questionnaire (MOXFQ). Secondary outcomes included Euroqol-5D, VAS Pain, and radiographic deformity correction. Results: Forty-seven feet underwent primary fourth-generation HV surgery and were stratified into 3 cohorts. There were 19, 16, and 12 feet in the normal, mild, and moderate cohorts respectively. There was no significant difference in either pre- or postoperative foot function (all MOXFQ domains, P > .05) or health-related quality of life (EQ-5D Index or VAS, P > .05). The MOXFQ Index preoperatively was as follows: normal cohort, 56.1 ± 26.9; mild cohort, 54.1 ± 17.9; and severe cohort, 49.6 ± 23.8; and postoperatively was as follows: normal cohort, 15.6 ± 21.5; mild cohort, 11.4 ± 15.5; and severe cohort, 11.4 ± 13.6 (P = .737-.908). There was significantly worse hallux valgus angle (HVA) and intermetatarsal angle (IMA) between the cohorts (P < .01). Although HVA and IMA were corrected to normal parameters following surgery in all cohorts, there was a significantly worse postoperative HVA in the moderate sesamoid coverage (5.3 ± 3.9 vs 7.9 ± 5.3 vs 11.4 ± 3.7, P < .01); however, IMA was not significantly different (3.4 ± 2.2 vs 4.1 ± 2.7 vs 5.2 ± 2.9, P = .168). Conclusion: This study found that cases where the sesamoids were not reduced had a poorer correction and had worse preoperative deformity. Clinical outcomes and foot function following fourth-generation percutaneous hallux valgus surgery were not affected by sesamoid coverage at the 12-month follow-up. The long-term implications in the difference in radiographic deformity between the 3 cohorts are not known, and further work should explore the relationship of first ray pronation and sesamoid position, particularly with regard to recurrence. [ABSTRACT FROM AUTHOR]

Background: Currently, more than 150 surgical techniques have been described for the treatment of hallux valgus. The abundance of techniques indicates that there is no technique that has been designated as a gold standard. In recent years, a particular interest in the use of minimally invasive techniques has grown. The aim of this study was to prospectively compare clinical, radiologic, and postoperative outcomes between the MICA technique and open chevron technique over a 1-year follow-up period. Methods: Between January 2016 and August 2020, data were prospectively collected from consecutive patients preoperatively and at 6 weeks, 3 months, and 12 months following minimally invasive chevron and Akin (MICA) or open chevron osteotomies. Radiographic outcomes were measured using weightbearing radiographs preoperatively and at 3 and 12 months postoperatively. Clinical outcomes were measured using the American Orthopaedic Foot & Ankle Society (AOFAS), Manchester-Oxford Foot Questionnaire (MOXFQ), VAS (visual analog scale), Foot Function Index (FFI), Foot and Ankle Outcome Score (FAOS), and Euro-QoL-5D (EQ5D) questionnaires. Results: Of the 68 patients, 42 patients (62%) underwent a MICA surgery and 26 patients (38%) underwent open chevron osteotomy. Both groups showed significant improvement in HVA, IMA, and DMAA at the 1-year follow-up. Our findings show that both clinical and radiologic outcomes of the MICA technique are comparable to the conventional open technique. No significant differences were found in clinical outcomes (VAS, AOFAS, MOXFQ, FFI, and FAOS), complication rate, and operative times. Conclusion: These results show that MICA is a safe alternative for chevron osteotomy. The clinical and radiologic outcomes of these 2 techniques by 12 months are comparable. [ABSTRACT FROM AUTHOR]

Background: Tarsometatarsal joint (TMJ) arthrodesis is common method used for correcting hallux abductus valgus (HAV). Its popularity has grown due to studies revealing HAV's triplanar deformity with frontal plane rotation. This case report presents a 28-year-old woman with Down syndrome, congenital heart disease, and a history of knee surgery and plantar fasciitis, with severe HAV deformity and flexible valgus flatfoot associated with ligamentous hyperlaxity. Case Report: Examination revealed severe foot deformities, and radiographic studies confirmed the condition. A surgical intervention was planned, and the patient's cardiologist confirmed she was fit for the procedure. The modified Lapidus technique with frontal plane rotational correction included realigning the metatarsal joint, resecting spurs, osteosynthesis material, and arthrosis in the sinus tarsi. After surgery, the patient underwent a recovery period without support for 8 weeks and received appropriate medical care. Radiographs showed successful alignment, and the patient gradually resumed her daily activities. The patient had an uneventful recovery, and postoperative radiographs showed good alignment in all planes. Conclusions: The hyperlaxity associated with Down syndrome makes the incidence of HAV more frequent, and TMJ fusion is preferable to correction by osteotomy. The modified Lapidus technique with frontal plane rotational correction could be a good technique to achieve satisfactory correction in patients with severe HAV deformity and flexible valgus flatfoot associated with ligamentous hyperlaxity. TMJ fusion is indicated when severe or recurrent rotational component is observed in X-rays. [ABSTRACT FROM AUTHOR]

Background: This study aims to describe the distribution of the dorsomedial cutaneous nerve (DMCN) in the middle and proximal parts of the metatarsal from a lateral view. The purpose is to provide guidance to surgeons in protecting the nerve during the 3rd and 4th generation minimally invasive surgery (MIS) for hallux valgus (HV). Methods: A total of 20 cadaveric feet were dissected to expose the course of the DMCN and sentinel vein. Measurements of the distances between the nerve/vein and the upper border of the metatarsal, as well as the height of the metatarsal, were taken from a lateral view. The distribution area was then described in proportion. Results: At the base of the metatarsal, the DMCN was distributed in the upper 25.7% of the area. When it reached the middle of the metatarsal, the DMCN was distributed in the upper 13.2–47.2% of the area. As for the sentinel vein, it was distributed in the upper 23.5–71.9% and upper 4.1–52.7%, respectively, at these two positions. Conclusions: The area, which is above the line connecting the upper 1/4 point at the base of the first metatarsal and the 1/2 point at the middle of the first metatarsal, is a dangerous zone for the DMCN. Avoiding the zone is recommended during MIS for HV. [ABSTRACT FROM AUTHOR]

Objective: Hallux valgus has a detrimental impact on health‐related quality of life. Education is crucial for the management of all musculoskeletal conditions, although no previous research has evaluated the sources and quality of education accessed by patients with hallux valgus. Therefore, we aimed to evaluate the perceptions and attitudes of individuals with hallux valgus, including their educational experiences. Methods: A qualitative descriptive design was employed to gather data from individuals diagnosed with painful hallux valgus. Semi‐structured interviews explored the perceptions, attitudes and educational experiences of participants. Interviews were recorded, transcribed verbatim, and analysed using the Framework Method. Respondent validation was used to ensure the rigour of the study findings. Results: Ten participants were interviewed, ages 26–72. Data analysis revealed five themes including the impact of hallux valgus, coping with hallux valgus, cause of hallux valgus, health professional support and education received. Hallux valgus was associated with a negative impact on health‐related quality of life. Participants described a lack of high quality, accurate and reliable educational resources, and a variable experience with health professionals, which was often characterised by a lack of engagement and commitment and an overemphasis of referrals for specialist opinion. Conclusion: Hallux valgus has a negative influence on well‐being, including physical, mental, and social impacts. Health professionals should be responsive to patient needs and strive to implement person‐centred care when indicated. There is also a need for the development of high‐quality educational resources to help people with hallux valgus make informed decisions about their condition. [ABSTRACT FROM AUTHOR]

Objective: Rotational Scarf osteotomy has its unique advantages in treating hallux valgus, but it also has certain drawbacks. The biomechanical differences between rotational Scarf and translational Scarf osteotomy are not clear evaluates the correction ability and biomechanical difference of two surgical methods for hallux valgus by finite element analysis. Methods: The computerized tomography data of a hallux valgus patient were selected to establish a finite element model. The standard Scarf osteotomy was simulated based on the model, and the rotation and translation were performed, respectively. The size of the intermetatarsal angle, contact area, distal metatarsal articular angle and the absolute length of the first metatarsal was compared between the two groups. We completed the cartilage, ligament and other tissues on the bone model to establish a full foot model. We analyzed the troughing, plantar aponeurosis tension, plantar soft tissue, and ground stress and also observed the stability of the fracture site by a three‐point bending test. Results: Both surgical methods may effectively correct the intermetatarsal angle. After rotational osteotomy, the contact area increased, and the length of the first metatarsal bone initially increased and then decreased compared to that in the translational group. Furthermore, rotational Scarf significantly increased the distal metatarsal articular angle. Mechanical analysis showed that the cancellous bone in the contact part of the fracture site in the translation group had greater stress, which was the reason for the occurrence of the troughing. Stress distribution of plantar aponeurosis, plantar soft tissue, and the ground showed no significant difference. The three‐point bending test showed that the separation of the broken ends of the rotational Scarf osteotomy model (0.133 mm) was slightly smaller than the translational group (0.147 mm). Conclusion: Both surgical methods can successfully correct intermetatarsal angle (IMA). Compared to traditional translational Scarf osteotomy, rotational Scarf osteotomy is more conducive to postoperative stability and healing, but it also has certain drawbacks. In clinical practice, individualized surgical methods still need to be selected for different types of patients with hallux valgus. [ABSTRACT FROM AUTHOR]

Hallux Valgus (HV) deformity, commonly known as a bunion, is a prevalent foot condition and a highly performed procedure across various insurance demographics. With the continuous growth of the Medicare population and its working share, the financial burden of incapacitating injuries like HV becomes more significant. Given the substantial proportion of bunionectomy surgeries performed on Medicare beneficiaries, it is imperative to explore how a significant shift from Traditional Medicare (TM) to Medicare Advantage (MA) coverage might impact patient access to bunionectomy surgeries. This study aims to evaluate the effect of Medicare type on patient access to bunionectomy procedures within Miami-Dade County, where the population is predominantly enrolled in Medicare and Medicare Advantage plans. The research seeks to understand potential differences in access to care, as disparities in access to podiatric care. The findings of this research will shed light on whether Medicare Advantage beneficiaries have greater access to bunionectomy procedures compared to Traditional Medicare beneficiaries in Miami-Dade County. By understanding the impact of Medicare type on access to care, policymakers, healthcare providers, and insurance companies can make informed decisions to improve patient outcomes and address potential disparities in healthcare access. The implications of this study are of great importance, considering the prevalence of HV and the rising Medicare population. Enhancing access to bunionectomy surgeries for Medicare beneficiaries can alleviate the financial burden on patients and the healthcare system and improve health outcomes in Miami-Dade County. Of the 100 clinics, 50 (50 %) accepted new patients for HV deformity evaluation, although only 31 (31%) had podiatric specialists currently performing bunionectomy surgeries. Traditional Medicare (TM) had the highest appointment success rate of 96.67%, and commercial coverage was comparable at 93.33% (p = .55). Our study found that patients in Miami-Dade County with Medicare Advantage (MA) have decreased access to Hallux Valgus deformity correction surgery (bunionectomy) compared to those with Traditional Medicare or commercial insurance; this could be a potential reason for lower rates of bunionectomy utilization in the MA population. [ABSTRACT FROM AUTHOR]

Objective: To determine inter-reader reliability (IRR) of hallux valgus (HV) related parameters, i.e. intermetatarsal angle (IMA), hallux valgus angle (HVA), lateral round sign of the first metatarsal, tibial sesamoid position (TSP), metatarsus adductus angle (MAA), transverse osseous foot width, 1st MT length, MTP osteoarthritis (OA), and distal metatarsal articular angle (DMAA). These were correlated with patient-reported outcome measures (PROMs). Materials and Methods: A prospective single-arm Level 3 multicenter clinical trial in which standardized radiographs and PROMs were collected at the time of the initial patient visit for pre-operative assessment. Two musculoskeletal radiologists performed measurements blinded to each other's reads and clinical information. Intraclass coefficient and kappa were obtained for inter-reader analysis. A partial spearman rank order was used to correlate the measurements with PROMs. Results: The final cohort size of 183 patients had mean age of 40.77 years, mean body mass index was 26.11 kg/m2, with 91.2% females and 8.7% males. There was excellent IRR for HVA (0.96, CI: [0.94,0.97]), IMA (0.92, CI: [0.89,0.94]), transverse osseous foot width (0.99, CI: [0.98,1.00]), and DMAA (0.80, CI: [0.74, 0.85]), good agreement for TSP (0.73, CI:[0.67,0.79]) and MAA (0.67, CI: [0.16, 0.84]), fair agreement for MTP OA (0.48, CI: [0.36,0.59]), and poor agreement for lateral round sign (0.32, CI: [0.11, 0.52]. The negative correlation of increasing transverse osseous foot width with worsening PROMIS physical but better MOxFQ and VAS scores is likely spurious. Conclusion: Good to excellent inter-reader reliability was observed for the most often used measurements for HV assessment without major trends in their correlations with PROMs. Lateral round sign is not a reliable finding in HV deformity. [ABSTRACT FROM AUTHOR]

Purpose: "Hallux valgus" is a common disease encountered in clinical practice and is accompanied by foot deformities. Conservative treatment is commonly used in the early stages of hallux valgus. On the other hand, surgical treatment often becomes necessary as the deformity progresses. Surgical treatments involve various osteotomy methods or joint fusion procedures combined with soft tissue release, and outcomes from these surgical treatments are generally favorable. This study compared two soft tissue release techniques in the hallux region. Materials and Methods: This study conducted a retrospective cohort study on 48 participants who underwent surgical treatment for hallux valgus at a single institution from March 1, 2018, to March 31, 2023. A scarf osteotomy was performed in all cases, and the "Modified Mcbride procedure" or "Trans-articular approach" was done for soft tissue release. Hallux valgus angle (HVA), intermetatarsal angle (IMA), and the degree of subluxation of the lateral sesamoid were measured through simple foot radiographs taken before surgery and one year after surgery. Results: In the Modified Mcbride procedure group, HVA, IMA, and the sesamoid position grade decreased from 34.94º to 9.98º, 15.64º to 5.44º, and 2.47 to 0.44, respectively. In the trans-articular approach group, HVA, IMA, and the sesamoid position grade decreased from 33.42º to 7.34º, 15.06º to 6.03º, and 2.17 to 0.58, respectively. There was no significant difference in these changes between the preoperative and one-year postoperative measurements for both techniques (p-value>0.05). Conclusion: A radiological assessment of soft tissue release through the Modified Mcbride procedure and trans-articular approach in hallux valgus did not show significant differences. Therefore, both surgical techniques can be considered in the distal soft tissue release for a hallux valgus correction. [ABSTRACT FROM AUTHOR]

Forefoot osteotomies to improve the alignment are difficult procedures and can lead to a variety of complications. Preoperative planning in three dimensions might assist in the successful management of forefoot deformities. The purpose of this study was to develop a global coordinate system in the foot for the planning of forefoot corrections. Two strategies (CS1 and CS2) were developed for defining a global coordinate system that meets the criteria of being well-defined, robust, highly repeatable, clinically relevant, compatible with foot CT scans, independent of the ankle joint angle, and does not include bones in the forefoot. The absolute angle of rotation was used to quantify repeatability. The anatomical planes of the coordinate systems were visually inspected by an orthopedic surgeon to evaluate the clinical relevancy. The repeatability of CS1 ranged from 0.48° to 5.86°. The definition of CS2 was fully automated and, therefore, had a perfect repeatability (0°). Clinically relevant anatomical planes were observed with CS2. In conclusion, this study presents an automated method for defining a global coordinate system in the foot according to predefined requirements for the planning of forefoot corrections. [ABSTRACT FROM AUTHOR]

The purpose of this systematic review is to examine the learning curve associated with minimally invasive surgery (MIS) for the treatment of hallux valgus (HV). A systematic review was performed using PubMed, ScienceDirect, Web of Science, CINAHL and MEDLINE databases from database inception to February 16th, 2023. Inclusion criteria was articles with level of evidence I-III, any outcomes associated with learning curve, minimally invasive surgery, and diagnosis of hallux valgus' in adult patients. Six articles out of 165 articles meet inclusion criteria. For all six articles, 368 total patients (422 total feet) were included in the study with an average age of 55.69 years. Three studies reported the number of surgeries needed to reach the plateau phase of the learning curve of MIS for HV, with a frequency weighted mean of 35.5 surgeries (range 27 – 40). In the selected articles, significant results were found for increased operating room (OR) time and fluoroscopy shots in the learning phase. There was no significant increase in complications in the learning phase. There was no significant decrease in patient outcomes, or the quality of correction performed during the learning phase. An average of 35.5 surgeries (range 27 – 40) are needed to reach the plateau phase for MIS for HV. The learning phase of the learning curve of MIS for HV has a significant increase in OR time and fluoroscopy usage. However, the learning phase of the learning curve of MIS for HV is not associated with decreased outcomes or higher complication rates based on the small sample size in this study. Level III, Systematic Review [ABSTRACT FROM AUTHOR]

An association between the medial partite hallux sesamoid (MPHS) and hallux valgus (HV) has been suggested; however, a causal relationship has not been confirmed. This study aimed to determine their causal relationship using a cross-sectional radiographic survey of a large-scale population cohort covering a wide age group. The fifth survey of the Research on Osteoarthritis/Osteoporosis against Disability study involved 1997 participants aged 21–95 years who had undergone anteroposterior radiography of bilateral feet. The presence of MPHS, its morphology, and radiographic parameters related to the HV were assessed using radiographs. Changes in the prevalence of MPHS with age were assessed using trend tests. The relationship between the MPHS and HV was assessed based on sex and age. MPHS was found in 508 out of 3994 feet (12.7 %), with a significant difference in prevalence between men and women (10.0 % vs. 13.7 %, p < 0.001). Trend analysis demonstrated a significant decrease in MPHS occurrence with age in both sexes. HV angle was significantly higher in feet with MPHS than in those without (Men: 17.8 ± 7.0° vs. 14.0 ± 5.9°, p < 0.0001; Women: 19.6 ± 7.7° vs. 17.7 ± 7.9°, p < 0.0001). The prevalence of HV angle ≥ 20° was also significantly higher in feet with MPHS than in those without (Men: 33.3 % vs. 14.6 %, p < 0.0001; Women: 46.5 % vs. 34.6 %, p < 0.0001). This association between MPHS and HV was noticeable in younger adults and became less prominent with age. MPHS is associated with HV. The weakening of this relationship and the decreased prevalence of MPHS with age suggest that MPHS is not caused by HV, but is one of the causes of HV, especially in younger adults. • The causal relationship between hallux valgus and medial partite hallux sesamoid has not been elucidated. • This study surveyed their relationship using a large-scale population cohort. • Medial partite hallux sesamoid is associated with hallux valgus; however, their relationship was weakened with age. • The prevalence of medial partite hallux sesamoid decreased with age. • The findings from the present study suggested that medial partite hallux sesamoid is not caused by hallux valgus, but is one of the causes of hallux valgus, especially in younger adults. [ABSTRACT FROM AUTHOR]

Epidemiological studies on hallux valgus (HV) are challenging owing to differences in sampling and diagnostic criteria across studies. This study aimed to indirectly clarify HV epidemiology using a national database. The age- and sex-stratified annual number rate of HV correction (RHVC) per 100,000 people in Japan during 2014–2019 were examined. The average annual RHVC was 3.0. RHVC had unimodal (peak, 65–79 years) and bimodal (peaks, 15–19 and 70–74 years) distributions among males and females, respectively, and increased over time in males aged 50–54 and 75–79 years and females aged 80–84 years. RHVC increases with increasing age and occurs commonly in female teens. The recent RHVC in Japan was lower than that reported in Europe and the United States, with an increasing trend among elderly people. III [ABSTRACT FROM AUTHOR]

Purpose: We compared the outcomes of arthrodesis of the first metatarsophalangeal joint for severe hallux valgus in 31 adolescents with cerebral palsy, using three different methods of fixation: K-wires, non-locking plates, and locking plates. Methods: Clinical outcomes included time to weight-bearing, fusion rates and surgical complications. Radiographic assessment included comparing pre- and post-operative hallux valgus angles, intermetatarsal angles, interphalangeal angles, and lateral metatarsophalangeal angles. Patient-reported outcomes included pre- and post-operative visual analogue scales addressing bunion pain and concerns, difficulties with wearing shoes and braces, and difficulties with foot hygiene. Results: Of the 31 adolescents (16 male), 10 patients had K-wire fixation, 11 had a non-locking dorsal plate, and 10 had fixation with a dorsal locking plate. Mean age at surgery was 16 years (12–18 years) and mean follow-up was 4 years (2.7–6.5 years). Patients with K-wire fixation had delayed weight-bearing and had more complications than those managed by dorsal plating. There were significant improvements in radiographic parameters (except interphalangeal angle) and in patient-reported outcomes, in all groups (p < 0.001). However, radiographic and clinical outcomes were better in the dorsal plating groups compared to the K-wire group. Conclusion: Arthrodesis of the first metatarsophalangeal joint gave good correction of deformity with improvements in symptoms and radiographic parameters in adolescents with cerebral palsy. We recommend dorsal plating that allowed early weight-bearing and had fewer complications with better clinical and radiographic outcomes, than K-wire fixation. Level of evidence: IV: Retrospective case series. [ABSTRACT FROM AUTHOR]

Background: The modified Lapidus arthrodesis is a standard procedure to correct middle to severe hallux valgus (HV) deformities. Recently, minimally invasive techniques of first metatarsocuneiform joint (MCJ) resection using a Shannon burr were described. The primary goal of this study is to compare the anatomical efficacy and safety of first MCJ resection using a straight 2 × 13-mm Shannon burr and minimally invasive technique (MIS) vs an open technique using an oscillating saw. Methods: Ten pairs of fresh frozen cadaveric feet were randomly assigned to open or MIS first MCJ resection with subsequent systematic dissection. For the MIS procedure, a dorsomedial approach was used and for the open procedure a medioplantar approach was used. Cartilage removal was investigated by analyzing standardized scaled photographs of the resected articular surfaces with ImageJ software. Nearby structures at risk were analyzed for iatrogenic violation: tibialis anterior (TA), extensor hallucis longus (EHL) and peroneus longus (PL) tendons, and the Lisfranc ligament complex (LLC). Results: In the MIS group, the median cartilage resection was 85.9% at the cuneiform and 85.6% at the metatarsal bone compared to 100% cartilage resection in open technique (P <.01). Iatrogenic damage of the LLC, EHL, and TA tendons was not found in any group. The PL tendon was thinned out (<25% of tendon thickness) in 4 cases (40%) in the open group and in 1 case (10%) in the MIS group. A safe zone of 3.0 mm between the articular surface of the cuneiform bone and the LLC was identified, which can be resected without putting the LLC at risk when performing lateral-based wedge resections. Conclusion: In this cadaver study with the procedures performed by an experienced foot and ankle surgeon, and using 2 different surgical approaches, we found general parity between the Shannon burr MIS technique vs oscillating saw open technique techniques with more risk to the PL with our open technique and approximately 15% less cartilage resection with our MIS technique. Level of Evidence: Level V, cadaver study. [ABSTRACT FROM AUTHOR]

Background: First metatarsophalangeal (MTP) arthrodesis is a common surgical intervention for addressing MTP pain and deformity. Despite great interest on the topic of return to sport (RTS) after first MTP arthrodesis in the literature, no systematic review exists on this topic. The purpose of this systematic review is to investigate RTS after first MTP arthrodesis. Methods: This study is a systematic review using PubMed, Web of Science, CINAHL, and MEDLINE from database inception until May 10, 2023. Search algorithm used was (MTPJ OR MTP OR "hallux rigidus" OR cheilectomy OR metatarsal OR metatarsophalangeal) AND (arthrodesis OR fusion) AND sport. Inclusion criteria were surgical intervention of first MTP arthrodesis and outcomes related to sport. Results: Ten articles were included out of 249 articles initially retrieved. Patients (n = 450) had a frequency weighted mean (FWM) age of 58.6 ± 5.1 years with a FWM follow-up time of 32.1 ± 18.9 months. A total of 153 patients (reported in 34.0% of patients) had a FWM postoperative Foot and Ankle Ability Measure Sport score of 70.4 ± 21.8 at final follow-up. For sporting activities reported by multiple studies (running, yoga, golf, hiking, tennis, elliptical, and biking), about 9.8% to 28.1% of patients (n = 69 reports) stated that sporting activity difficulty decreased, 67.2% to 87.5% of patients (n = 340 reports) stated that sporting activity remained the same, and 1.8% to 8.5% of patients (n = 23 reports) stated that sporting activity difficulty increased after first MTP arthrodesis depending on the sporting activity. One article reported RTS time of 11.7 ± 5.1 weeks after first MTP arthrodesis (n = 39). Conclusion: RTS after first MTP arthrodesis is highly variable depending on patient and sport. Numerous different sporting activities have high rates of RTS after first MTP arthrodesis, with a majority of patients reporting similar or increased ability to perform sporting activities after surgery. [ABSTRACT FROM AUTHOR]

Background: The purpose of this study was to determine the results of an arthrodesis technique of the first metatarsophalangeal joint (MTPJ) using a precontoured dorsal plate to correct the hallux valgus deformity. Methods: This was a retrospective analysis of outcomes for first MTPJ arthrodesis performed using 2 precontoured dorsal plates. Radiographic outcomes (intermetatarsal angle [IMA] and hallux valgus angle [HVA]) and patient-reported functional outcome measures (Short-Form 12 and Foot and Ankle Outcome Score) were recorded and compared. Results: Fifty-five patients underwent 77 first MTPJ arthrodeses for severe hallux valgus deformity with associated degenerative changes at the first MTPJ. The mean reduction of the IMA was 5.67° (P <.05) and the mean reduction of the HVA was 33° (P <.05). The Short-Form 12 assessment of global health demonstrated a significant improvement in both the physical and mental health composite scores by 16.4 points and 10.4 points (P <.05), respectively. The Foot and Ankle Outcome Score demonstrated a cumulative decrease of 35% (59.28; P <.05) in all domains. Conclusions: First MTPJ arthrodesis using a precontoured dorsal plate is a successful procedure with a high union rate, low complication rate, and a high level of patient-reported satisfaction. Levels of Evidence: Level III. [ABSTRACT FROM AUTHOR]

Introduction: Overcorrection is a possible complication of clubfoot treatment, whose prevalence varies from 5 to 67%. Overcorrected clubfoot usually presented as a complex flatfoot with different degrees of hindfoot valgus, flat top talus, dorsal bunion, and dorsal navicular subluxation. The management of clubfoot overcorrection is challenging, and both conservative and surgical treatments are available. This study aims to present our experience in the surgical management of overcorrected clubfoot and to provide an overview of actual treatment options for each specific sub-deformity. Materials and methods: A retrospective cohort study of patients surgically treated for an overcorrected clubfoot from 2000 to 2015 at our Institution was conducted. Surgical procedures were tailored to the type and symptomatology of the deformity. A medializing calcaneal osteotomy or subtalar arthrodesis was performed for hindfoot valgus. Subtalar and/or midtarsal arthrodesis were considered in cases of dorsal navicular subluxation. The first metatarsus elevatus was addressed through a proximal plantarflexing osteotomy, sometimes associated with a tibialis anterior tendon transfer. Clinical scores and radiographic parameters were obtained pre-operatively and at the last follow-up. Results: Fifteen consecutive patients were enrolled. The series included 4 females and 11 males, with a mean age at surgery of 33,1 (18–56) years, and a mean follow-up of 4,46 (2–10) years. Seven medializing calcaneal osteotomies, 5 subtalar arthrodesis, 11 first metatarsal plantarflexing osteotomies, and 7 anterior tibialis tendon transfers were performed. A statistically significant improvement in both clinical and radiographic scores was observed. Conclusions: Management of overcorrected clubfoot involves many surgical techniques because of the high interpersonal variability of the deformities. The surgical approach showed positive results, as long as the indication is based on clinical symptoms and functional impairment rather than morphological alterations and radiographic findings. [ABSTRACT FROM AUTHOR]

Objective: To design appropriate orthosis for hallux valgus, a difficult foot condition that affects a quarter of the body's bones, we need to clarify the numerical biomechanical features, which have not been established in previous biomechanical studies. Therefore, we constructed a finite element model of the bunion foot to investigate the orthopaedic force compensation mechanism. Methods: A patient with moderate hallux valgus was recruited. CT imaging data in DICOM format were extracted for three‐dimensional foot model reconstruction. In conjunction with the need for rapid design of bunion orthosis, a metatarsal force application sizing method based on an orthogonal test design was investigated. The orthogonal test design was used to obtain the hallux valgus angle (HVA) and the inter metatarsal angle (IMA) data for different force combinations. Based on the extreme difference analysis and analysis of variance of the test results, the influence of different force combinations on the bunion angle was quickly determined. Results: The results showed that the stress concentration occurred mainly in the first metatarsal bone. The distribution trend was in the medial and lateral middle of the bone and gradually decreased to the dorsal base of the bone body. The greatest stress occurs in the cartilage between the phalanges and metatarsals. In 25 groups of simulation experiments, HVA was reduced from 27.7° to 13°, and IMA was reduced from 12.5° to 7.3°. Conclusion: Applying detailed orthopaedic force collocation to the first metatarsal column can effectively restore the mechanics and kinematics of hallux valgus, and provide a reference for the treatment of bunion valgus and the design of orthopaedic devices. [ABSTRACT FROM AUTHOR]

Various modifications of distal chevron metatarsal osteotomy (DCMO) have been introduced for correcting moderate hallux valgus deformity; however, the amount of correction may be limited, and complications, such as the recurrence of the deformity and avascular necrosis of the metatarsal head, have been a problem. This study aimed to present a modified 90-degree DCMO technique that overcomes the previously reported shortcomings and to report a successful short-term radiographic outcome. Sixty-eight consecutive patients who underwent the operation with our modified DCMO technique and twenty-two consecutive patients with the conventional DCMO technique (control group) were retrospectively analyzed. The radiographic measurements were evaluated preoperatively, at two months post operation, and at the final follow-up. Both groups showed a significant correction of the hallux valgus angle, first–second intermetatarsal angle, distal metatarsal articular angle, and sesamoid position at the final follow-up, while the amount of correction was significantly greater in the modified DCMO group. In both groups, there were no cases of complications such as avascular necrosis of the metatarsal head, nonunion, and surgical site infection appearing throughout the follow-up period. Therefore, the modified 90-degree DCMO technique is effective and safe, which could serve as a favorable option to treat moderate hallux valgus deformity. [ABSTRACT FROM AUTHOR]

The os intermetatarseum is an accessory bone located in the foot, usually between the first 2 metatarsals and the cuneiform bone. It can be presented as free, articulated or in a fused fashion. It is a very unusual variation found in less than 13 % of the population. A 27-year-old patient presented to the emergency service due to an ankle lesion. Physical exam showed pain and limited range of motion while supporting partial load. Radiographic imaging showed a bony trace near the base of the first and second metatarsals, diagnosed as the os intermetatarseum. Formation of this supernumerary bone begins as a separate ossification center. Most cases are asymptomatic; however, compression of the deep peroneal nerve branches by the os intermetatarseum can lead to pain. Some authors suggest that the presence of this bone may cause hallux valgus. The intermetatarseum can lead to diagnostic confusion, mainly related to Lisfranc fracture. Its origin is still little understood. [ABSTRACT FROM AUTHOR]

Introduction: Rheumatoid arthritis (RA) is a chronic, inflammatory, connective tissue disease, leading to foot deformities, impairment of locomotive functions, and reducing patients' quality of life. Obesity prevalence is rising in early RA and is associated with worse disease activity, function and health-related quality of life, with a significant negative impact on achieving a low Disease Activity Score in 28 joints (DAS28). The aim of the study was to evaluate foot deformities in overweight RA patients according to the severity of the disease. Material and methods: The study was performed on 50 overweight women with RA. The control group consisted of 50 overweight women free of any disorders. Plantography examination was carried out by means of a CQ ST 2K podoscope. Rheumatoid arthritis disease activity was assessed by DAS28. Activity limitation was assessed using the Health Assessment Questionnaire (HAQ) and foot posture by the Foot Posture Index (FPI-6). Body composition analysis was performed using In Body 220. Results: Hallux valgus was the most frequent deformation in RA patients with overweight. Longitudinal flat foot was much more frequent in RA patients than transverse flat foot. A relationship between fat tissue mass and presence of transverse flat foot in RA patients with overweight was found. In this group DAS28, VAS, and Clarke's angle were correlated with increased value of HAQ. Conclusions: Plantar contourography showed a trend of an increase of a angle values and the Sztriter-Godunow index (KY) in overweight RA patients with increasing severity of radiological changes and DAS28, requiring use of proper prevention and therapeutic strategies of destructive changes. [ABSTRACT FROM AUTHOR]

Key Clinical Message: Fibrodysplasia ossificans progressiva is a progressively debilitating condition associated with significant morbidity caused by heterotopic ossification. Recognition of the early signs of hallux valgus and painful soft tissue nodules can assist in the early diagnosis of this condition. Periodic radiographic examination is mandatory to monitor the disease progression. Fibrodysplasia ossificans progressiva is a rare condition with an estimated prevalence of one in two million individuals. The condition is characterized by widespread heterotrophic ossification of skeletal muscles and ligaments. We report the case of an 8‐year‐old female patient and show the radiological progression of the condition. [ABSTRACT FROM AUTHOR]

Background Up to one-third of Lisfranc injuries (an injury affecting the normal stability, alignment, and congruency of the tarsometatarsal joints) are misdiagnosed. Delayed diagnosis and improper treatment may lead to long-term, irreversible sequela and functional disability. Recently, the employment of three-dimensional (3D) CT demonstrated higher diagnostic reliability, but there is limited evidence on this, and radiologic features of Lisfranc injuries when using this diagnostic modality are not well described. Question/purpose What is the diagnostic performance of several novel radiographic signs on 3D CT when evaluating for Lisfranc injury, namely the Mercedes sign, the peeking metatarsal sign, and the peeking cuneiform sign, and what is the interobserver and intraobserver reliability of those diagnostic signs? Methods In this retrospective, diagnostic study, video clips of 3D CT reconstructions of 52 feet with intraoperatively confirmed Lisfranc injuries and 50 asymptomatic feet with a normal appearance of the tarsometatarsal joints, as ascertained by a subspecialtytrained foot and ankle surgeon and a musculoskeletal radiologist, were analyzed by two foot and ankle specialists and three orthopaedic residents twice each, with a washout period of 2 weeks. Among the 52 patients with intraoperative evidence of Lisfranc injury, there were 27 male patients and 25 female patients, with a median (IQR) age of 40 years (23 to 58); among the 50 controls, there were 36 male and 14 female patients, with a median age of 38 years (IQR 33 to 49). For each video clip, the presence of all three radiographic signs was documented (each sign was rated in a binary yes/no fashion). Before the evaluations, all observers underwent a short training session by the head of the foot and ankle department. Later, these reading were used to assess for the sensitivity, specificity, and area under the receiver operating characteristic curve in terms of Lisfranc diagnosis against the gold standard of intraoperative testing of tarsometatarsal joint stability. Intraoperatively, the congruency and stability of the second tarsometatarsal joint had been evaluated by direct visualization and by the insertion of a probe into the joint between the base of the second metatarsus and the medial cuneiform and twisting the probe to assess for stability. The individuals evaluating the video clips were unaware of the surgically obtained diagnosis at the time they performed their evaluations. Results All 3D radiographic signs that were examined had excellent diagnostic reliability in terms of sensitivity and specificity, ranging from 92% to 97% and from 92% to 93%, respectively. When assessing the association between the suggested 3D radiographic signs and Lisfranc injury diagnosis as a function of the area under the receiver operating characteristic curve, the Mercedes sign demonstrated a higher area under the curve than the other signs did (0.91 versus 0.87 versus 0.8; p < 0.001). The mean intraobserver and interobserver reliability (kappa) values were excellent for all 3D radiographic signs that were evaluated. Conclusion The proposed radiographic findings demonstrated excellent diagnostic performance and were repeatable within and among observers. Three-dimensional CT radiographic signs could function as a valuable diagnostic tool for the evaluation and initial screening for Lisfranc injury in the acute injury phase because obtaining AP bilateral standing radiographs of the foot is often impractical in the acute setting. Further research and comparison with AP weightbearing radiographs of the bilateral feet may be warranted. Level of Evidence Level III, diagnostic study. [ABSTRACT FROM AUTHOR]

Introduction: Overcorrection is a possible complication of clubfoot treatment, whose prevalence varies from 5 to 67%. Overcorrected clubfoot usually presented as a complex flatfoot with different degrees of hindfoot valgus, flat top talus, dorsal bunion, and dorsal navicular subluxation. The management of clubfoot overcorrection is challenging, and both conservative and surgical treatments are available. This study aims to present our experience in the surgical management of overcorrected clubfoot and to provide an overview of actual treatment options for each specific sub-deformity. Materials and methods: A retrospective cohort study of patients surgically treated for an overcorrected clubfoot from 2000 to 2015 at our Institution was conducted. Surgical procedures were tailored to the type and symptomatology of the deformity. A medializing calcaneal osteotomy or subtalar arthrodesis was performed for hindfoot valgus. Subtalar and/or midtarsal arthrodesis were considered in cases of dorsal navicular subluxation. The first metatarsus elevatus was addressed through a proximal plantarflexing osteotomy, sometimes associated with a tibialis anterior tendon transfer. Clinical scores and radiographic parameters were obtained pre-operatively and at the last follow-up. Results: Fifteen consecutive patients were enrolled. The series included 4 females and 11 males, with a mean age at surgery of 33,1 (18–56) years, and a mean follow-up of 4,46 (2–10) years. Seven medializing calcaneal osteotomies, 5 subtalar arthrodesis, 11 first metatarsal plantarflexing osteotomies, and 7 anterior tibialis tendon transfers were performed. A statistically significant improvement in both clinical and radiographic scores was observed. Conclusions: Management of overcorrected clubfoot involves many surgical techniques because of the high interpersonal variability of the deformities. The surgical approach showed positive results, as long as the indication is based on clinical symptoms and functional impairment rather than morphological alterations and radiographic findings. [ABSTRACT FROM AUTHOR]

Background. Minimally invasive surgical interventions are widely used in trauma and orthopedic surgery. Both the surgical technique and the instruments applied are being improved, which contributes to better functional results of patients’ treatment. Aim of the study — to present a new guide tool for minimally invasive surgical correction of acquired hallux valgus. Guide description. A guide tool intended to be used in minimally invasive surgical interventions for hallux valgus (HV) correction has been developed. It consists of several interconnecting components: the distal bar, the intramedullary guide, the proximal bar, and the wire guide. These components are fixed to each other. At the same time, the distal bar, the proximal bar, and the wire guide are connected with the possibility of adjusting their mutual positioning. The design of the proposed device enables to guide the first guiding wire and to place the cannulated screw in an optimal position. The presented clinical case illustrates the successful application of the described device. The patient underwent minimally invasive distal corrective osteotomy for hallux valgus of medium severity. According to the preoperative X-rays, the first intermetatarsal angle and the first toe deviation angle were 13.5° and 25°, respectively. Six months after the surgery, they were 3° and 7°, respectively. The result of the corrective surgery was considered excellent. Conclusion. Application of the proposed guide tool decreases surgery duration, reduces soft tissue damage and minimizes radiation exposure of the surgeon and the patient.

Background: The outcomes of first metatarsal (M1) distal osteotomies in hallux valgus (HV) can be improved, especially for intermetatarsal angle (IMA) correction, which is mainly based on lateral displacement of the M1 head (i.e., translation) through the osteotomy. Conversely, there is a spontaneous reduction in the IMA in first metatarsophalangeal joint (MTP1) arthrodesis. But we do not know whether this can be applied to distal osteotomies. We propose a distal osteotomy, called 3D chevron, which combines supination and varization of the M1 head. This might realign soft tissues around the MTP1, potentially leading to a spontaneous reduction in the IMA by an analogous mechanism to MTP1 fusion. Therefore, our study aimed to assess whether spontaneous reductions in IMAs exist in distal M1 osteotomies in the absence of lateral translations of M1 heads. Methods: A prospective continuous series of 25 3D chevrons was performed. Two groups were formed during surgery. Patients requiring no M1 head lateral displacement were included in the “successful correction without translation” group, and patients requiring M1 head lateral displacement were included in the “failed correction without translation” group. Radiographic analysis was performed preoperatively and at 1 year postoperatively. Results: Twenty-two women and three men, with a mean age of 44.8 ± 14.2 years and a mean body mass index of 22.6 ± 4.1 kg/m2, underwent follow-up at one year after surgery. The “successful correction without translation” group was composed of HV with milder deformities (13/25 HVs, median preoperative IMA = 13 (IQR 2)) compared to the “failed correction without translation” group (median IMA = 16 (IQR 2.25) p < 0.001). Spontaneous reductions in IMAs were observed in the “successful correction without translation” group, with a median decrease in the IMA of 6 degrees (CI95%[5.5; 8.0]; p < 0.001) between preoperative and 1-year radiographs. Conclusion: Distal osteotomies allow for spontaneous reduction in the IMA in HV. First metatarsal head translation through an osteotomy should not be considered as the only procedure to correct IMAs in distal osteotomies.

Objective evaluations of transverse tarsometatarsal (TMT) hypermobility/instability are lacking. This study aims to radiographically explore the relationship between transverse TMT instability and metatarsus adductus (MA) in hallux valgus (HV). This study retrospectively analyzed 207 feet with varying degrees of HV, employing the distance between the first and second metatarsals (M1-2 distance) to assess transverse TMT instability of the first ray. Participants were categorized into MA and non-MA groups. It was found that the M1-2 distance significantly increased with the hallux valgus angle (HVA) and metatarsus adductus angle (MAA), demonstrating significant differences between the MA and non-MA groups. The measurement of M1-2 distance showed high reliability, and its cutoff value was determined to be 4.05 mm. Additionally, the results suggest that the widening of the M1-2 distance may be a predisposing factor for MA in HV patients, highlighting its role in the pathogenesis of this foot condition. These findings highlight the need for a comprehensive assessment of TMT instability on both the axial and sagittal planes for the surgical planning of HV, particularly when complicated by a large MAA. Based on these insights, reoriented first-TMT arthrodesis might be recommended for HV with significant MA to address potential multiplanar instability.

Background: Central metatarsal pressure is increased in patients with hallux valgus, but the pedographic outcomes after hallux valgus (HV) correction are inconclusive. No known literature has reported the pedographic outcomes after HV correction with Minimally Invasive Chevron and Akin Osteotomy (MICA). Methods: A prospective cohort of 31 feet from 25 patients with moderate-to-severe symptomatic HV but without metatarsalgia underwent MICA and was evaluated using radiographic parameters and pedographic measurements (Footscan®, RSscan International, Olen, Belgium). Data were collected preoperatively and 3 months after surgery. Results: The radiographic parameters of the hallux valgus angle, intermetatarsal angle, distal metatarsal articular angle, first metatarsal head lateral shape, and lateral sesamoid grade significantly improved after MICA. The corrected first metatarsal length was significantly shortened by 2.3 mm, with consistent second metatarsal protrusion distance, lateral Meary’s angle, and calcaneal pitch angle. Max force, max pressure, cumulative force, and cumulative pressure on the central metatarsals did not show significant changes between pre- and post-operative measurements, while these parameters significantly decreased in the hallux and first metatarsal area. Conclusion: MICA effectively corrects radiographic parameters but does not reduce central metatarsal loading in patients with moderate-to-severe HV without metatarsalgia.

Introduction: It has long been accepted that trauma is one of the most important and frequent predisposing factors for onychomycoses. However, the role of direct trauma in the pathogenesis of fungal nail infections has only recently been elucidated in a series of 32 cases of post-traumatic single-digit onychomycosis. The importance of repeated trauma due to foot and toe abnormalities was rarely investigated. Aimof the study: This is a multicenter single-author observational study over a period of 6 years performed at specialized nail clinics in three countries. All patient photographs taken by the author during this period were screened for toenail alterations, and all toe onychomycosis cases were checked for whether they contained enough information to evaluate potential foot and toe abnormalities. Particular attention was paid to the presence of hallux valgus, hallux valgus interphalangeus, hallux erectus, inward rotation of the big toe, and outward rotation of the little toe, as well as splay foot. Only cases with unequivocal proof of fungal nail infection by either histopathology, mycologic culture, or polymerase chain reaction (PCR) were accepted. Results: Of 1653 cases, 185 were onychomycoses, proven by mycologic culture, PCR, or histopathology. Of these, 179 involved at least one big toenail, and 6 affected one or more lesser toenails. Three patients consulted us for another toenail disease, and onychomycosis was diagnosed as a second disease. Eight patients had a pronounced tinea pedum. Relatively few patients had a normal big toe position (n = 9). Most of the cases had a mild to marked hallux valgus (HV) (105) and a hallux valgus interphalangeus (HVI) (143), while hallux erectus was observed in 43 patients, and the combination of HV and HVI was observed 83 times. Discussion: The very high percentage of foot and toe deformations was surprising. It may be hypothesized that this is not only a pathogenetically important factor but may also play an important role in the localization of the fungal infection, as no marked hallux deviation was noted in onychomycoses that affected the lesser toes only. As the management of onychomycoses is a complex procedure involving the exact diagnosis with a determination of the pathogenic fungus, the nail growth rate, the type of onychomycosis, its duration, and predisposing factors, anomalies of the toe position may be important. Among the most commonly mentioned predisposing factors are peripheral circulatory insufficiency, venous stasis, peripheral neuropathy, immune deficiency, and iatrogenic immunosuppression, whereas foot problems are not given enough attention. Unfortunately, many of these predisposing and aggravating factors are difficult to treat or correct. Generally, when explaining the treatment of onychomycoses to patients, the importance of these orthopedic alterations is not or only insufficiently discussed. In view of the problems encountered with the treatment of toenail mycoses, this attitude should be changed in order to make the patient understand why there is such a low cure rate despite excellent minimal inhibitory drug concentrations in the laboratory.