Metatarsophalangeal joint stability: A systematic review on the plantar plate of the lesser toes

Background: Instability of the metatarsophalangeal (MTP) joints of the lesser toes (digiti 2-5) is increasingly being treated by repair of the plantar plate (PP). This systematic review examines the anatomy of the plantar plate of the lesser toes, and the relation between the integrity of the plantar plates of the lesser toes and lesser MTP joint stability. Methods: The databases of Embase.com, Medline (Ovid), Web of Science, Scopus, Cochrane, Pubmed not medline, Cinahl (ebsco), ProQuest, Lilacs, Scielo and Google Scholar were searched in June 2015 from inception. Studies were included if they were in English, contained primary data, and had a focus on plantar plate anatomy of the lesser toes or on the relationship between integrity of the plantar plate and MTP joint (in)stability. Study characteristics were extracted into two main tables and descriptive anatomical and histological data were summarized into one schematic 3D drawing of the plantar plate. Results: Nine studies were included in this systematic review, of which five addressed plantar plate anatomy as such and four focused directly and indirectly on plantar plate integrity related to MTP joint stability. Conclusion: This is the first systematic review regarding plantar plate anatomy related to MTP joint stability of the lesser toes. This review iterates the importance of plantar plate anatomy and integrity for MTP joint stability, and it delineates the lack of primary data regarding plantar plate anatomy of the lesser toes and MTP joint stability

Forefoot deformity surgical reconstruction outcomes in people living with rheumatoid arthritis in South Africa

Introduction: Involvement of the forefoot is common among patients with Rheumatoid Arthritis. It results in severe deformities with significant disabilities. Aim: The aim of this study was to compare and assess in patients with Rheumatoid Arthritis in a South African population the outcomes of severe forefoot deformity reconstruction surgery in the short- to medium-term and in particular focusing on radiological, clinical, and functional outcomes. Patients and Methods: A retrospective review of 19 patients who received reconstructive forefoot surgery for forefoot deformities resulting from Rheumatoid Arthritis was undertaken. They all underwent Modified Hoffman Surgical Reconstruction (first MTPJ fusion and lesser toe resection arthroplasty). The patient records between 2013 and 2016 were reviewed. Pre-operative and post-operative outcome scores were collected. Final postoperative radiographs were analyzed. Patients completed Short Form 36 and AOFAS forefoot scores. Post-operative scores were collected 6 months post-op. Results: There were 19 patients in the study with a minimum 6 months follow up. Of the 19 patients 17 (89.5%) were females and 2 (10.5%) males. The mean age was 54.9 ± 9.6 years (range: 34 – 69 years). Most patient outcomes (SF36, AOS alignment, VAS Pain percentage, and VAS Disability percentage) significantly improved with a p value 0.05). Conclusion: Reconstructive forefoot surgery with the Modified Hoffman Surgical Reconstruction provides marked radiological correction, with significant improvements in the quality of life of the cohort of patients

Medium-Long-Term Clinical and Radiographic Outcomes of Minimally Invasive Distal Metatarsal Metaphyseal Osteotomy (DMMO) for Central Primary Metatarsalgia: Do Maestro Criteria Have a Predictive Value in the Preoperative Planning for This Percutaneous Technique?

The purpose of this prospective study was first to evaluate the safety and effectiveness of Minimally Invasive Distal Metatarsal Metaphyseal Osteotomy (DMMO) in treating central metatarsalgia, identifying possible contraindications. The second objective was to verify the potential of DMMO to restore a harmonious forefoot morphotype according to Maestro criteria. Methods. A consecutive series of patients with metatarsalgia was consecutively enrolled and treated by DMMO. According to Maestro criteria, preoperative planning was carried out by both clinical and radiological assessment. Patient demographic data, AOFAS scores, 17-FFI, MOXFQ, SF-36, VAS, and complications were recorded. Maestro parameters, relative morphotypes, and bone callus formation were assessed. Statistical analysis was carried out (p<0.05). Results. Ninety-three patients (93 feet) with a mean age of 62.4 (31-87) years were evaluated. At mean follow-up of 58.7 (36-96) months, all of the clinical scores improved significantly (p<0.0001). Most of the osteotomies (76.3%) had healed by 3-month follow-up, while ideal harmonious morphotype was restored only in a few feet (3.2%). Clinical and radiological outcomes were not different based on principal demographic parameters. Long-term complications were recorded in 12 cases (12.9%). Conclusion. DMMO is a safe and effective method for the treatment of metatarsalgia. Although Maestro criteria were useful to calculate the metatarsal bones to be shortened and a significant clinical improvement of all scores was achieved, the ideal harmonious morphotype was restored only in a few feet. Hence, our data show that Maestro criteria did not have a predictive value in clinical outcomes of DMM

Form and Function of the Anthropoid Forefoot

The transition to our uniquely human gait—terrestrial bipedalism—is the hallmark of our lineage. Abundant fossil evidence confirms that it was the adoption of a terrestrial bipedal gait that first set hominins apart from other apes. Therefore, a thorough understanding of postcranial functional morphology is necessary in order to gain as much insight as possible from the current known fossil material. When compared to our closest relatives, the living apes, it is clear that a suite of morphological changes have occurred in the human postcranial skeleton broadly, including modifications at the vertebral column, shoulder, wrist, hand, pelvis, ankle and foot. The human foot in particular is strikingly different from that of any other primate, and a better understanding of its functional morphology would allow researchers to better reconstruct the locomotor behavior of extinct hominin groups. Despite their theorized importance in bipedal locomotion, the morphological details of the anthropoid forefoot (i.e. | metatarsophalangeal) joints have not been thoroughly quantified. To that end, I present here a detailed morphometric analysis of anthropoid forefoot shape and form using modern 3-dimensional geometric morphometric (3DGM) techniques in a broad phylogenetic context in order to capture functionally meaningful aspects of forefoot shape. The appositional articular surfaces of the metatarsus and proximal pedal phalanges were quantified, and then hypotheses about forefoot functional morphology were tested by exploring shape space, constant and variable-rate models of shape evolution, patterns of forefoot joint covariance, and the correlation between forefoot morphology and kinematic performance. Results revealed several broad patterns in anthropoid forefoot evolution. First, it seems the lateral forefoot began to evolve first, with the hallux retaining a primitive form until relatively late in evolution; a similar pattern was found in the pedal phalanges, which looked more primitive than the metatarsals overall. This staggered timing of forefoot evolution perhaps reflects the importance of arboreal locomotion persisting well into the hominin lineage. Evidence of convergent evolution between highly terrestrial cercopithecoids and hominins was found. Correlations with kinematic data in human and chimpanzee forefoot joints suggest that dorsal robusticity is strongly correlated with forefoot dorsiflexion range of motion. | The transition to our uniquely human gait—terrestrial bipedalism—is the hallmark of our lineage. Abundant fossil evidence confirms that it was the adoption of a terrestrial bipedal gait that first set hominins apart from other apes. Therefore, a thorough understanding of postcranial functional morphology is necessary in order to gain as much insight as possible from the current known fossil material. When compared to our closest relatives, the living apes, it is clear that a suite of morphological changes have occurred in the human postcranial skeleton broadly, including modifications at the vertebral column, shoulder, wrist, hand, pelvis, ankle and foot. The human foot in particular is strikingly different from that of any other primate, and a better understanding of its functional morphology would allow researchers to better reconstruct the locomotor behavior of extinct hominin groups. Despite their theorized importance in bipedal locomotion, the morphological details of the anthropoid forefoot (i.e. | metatarsophalangeal) joints have not been thoroughly quantified. To that end, I present here a detailed morphometric analysis of anthropoid forefoot shape and form using modern 3-dimensional geometric morphometric (3DGM) techniques in a broad phylogenetic context in order to capture functionally meaningful aspects of forefoot shape. The appositional articular surfaces of the metatarsus and proximal pedal phalanges were quantified, and then hypotheses about forefoot functional morphology were tested by exploring shape space, constant and variable-rate models of shape evolution, patterns of forefoot joint covariance, and the correlation between forefoot morphology and kinematic performance. Results revealed several broad patterns in anthropoid forefoot evolution. First, it seems the lateral forefoot began to evolve first, with the hallux retaining a primitive form until relatively late in evolution; a similar pattern was found in the pedal phalanges, which looked more primitive than the metatarsals overall. This staggered timing of forefoot evolution perhaps reflects the importance of arboreal locomotion persisting well into the hominin lineage. Evidence of convergent evolution between highly terrestrial cercopithecoids and hominins was found. Correlations with kinematic data in human and chimpanzee forefoot joints suggest that dorsal robusticity is strongly correlated with forefoot dorsiflexion range of motion. | 311 page

Influence of the biomechanical evaluation of rupture using two shapes of same intramedullary implant after proximal interphalangeal joint arthrodesis to correct the claw/hammer pathology: A finite element study

We used finite element analysis to study the mechanical stress distribution of a new intramedullary implant used for proximal interphalangeal joint (PIPJ) arthrodesis (PIPJA) to surgically correct the claw‐hammer toe deformity that affects 20% of the population. After geometric reconstruction of the foot skeleton from claw toe images of a 36–year‐old male patient, two implants were positioned, in the virtual model, one neutral implant (NI) and another one 10° angled (10°AI) within the PIPJ of the second through fourth HT during the toe‐off phase of gait and results were compared to those derived for the non‐surgical foot (NSF). A PIPJA was performed on the second toe using a NI reduced tensile stress at the proximal phalanx (PP) (45.83 MPa) compared to the NSF (59.44 MPa; p &lt; 0.001). When using the 10°AI, the tensile stress was much higher at PP and middle phalanges (MP) of the same toe, measuring 147.58 and 160.58 MPa, respectively, versus 59.44 and 74.95 MPa at corresponding joints in the NSF (all p &lt; 0.001). Similar results were found for compressive stresses. The NI reduced compressive stress at the second PP (−65.12 MPa) compared to the NSF (−113.23 MPa) and the 10°AI (−142 MPa) (all p &lt; 0.001). The von Mises stresses within the implant were also significantly lower when using NI versus 10°AI (p &lt; 0.001). Therefore, we do not recommend performing a PIPJA using the 10°AI due to the increase in stress concentration primarily at the second PP and MP, which could promote implant breakage

Modern issues of surgical anatomy of the ligamentary apparatus and metatarsal bones of the human foot

The article presents an analysis of scientific literature devoted to the study of surgical anatomy of the ligamentous apparatus and metatarsal bones of the human foot. The literature covers the issues of macroanatomy and histology of the ligaments and metatarsal bones of the foot quite fully. At the same time, issues related to the same shape and size of bones, the relative position of ligaments, their histotopographic features are contradictory, which is associated with high variability, individual and age variability in combination with a number of social factors and features of the regions of residence. The work shows that at present, the data of domestic and foreign scientific literature on the anatomy and topography of the bones and ligaments of the metatarsal bones of the human foot are presented either by sectional studies or by the results of clinical observations using diagnostic equipment. The existing studies do not provide a comprehensive picture of the surgical anatomy of the ligamentous apparatus and metatarsal bones of the human foot. The article reflects the need for widespread use in fundamental anatomical studies of ligaments and metatarsal bones using the histotopographic method of research, quantitative and qualitative assessment of morphological parameters, which open up new possibilities for diagnosing pathological processes and developing new surgical techniques

Manipulation of the foot in the treatment of patients with Morton’s neuroma

Introduction Manipulative therapy’s rationale is pragmatically appealing as a non-invasive treatment for Morton’s neuroma (MN), involving targeted manipulations of relevant joints. Nevertheless, manipulation’s efficacy has received limited scrutiny. This thesis comprised four data-driven chapters offering novel investigations associated with manipulation as a treatment for MN. The latter included a critical appraisal of the clinimetric utility of pressure testing for discomfort thresholds (PTT) as a novel outcome in this context (n = 26; Chapter 5), an exploratory pragmatic controlled trial investigating Manipulation versus Steroid Injection in the treatment of patients with Morton’s neuroma focusing on self-reported pain levels (VAS) and PTT (n = 61; Chapter 6) and other PROMs reflecting functionality and health (Chapter 7). A final data chapter (Chapter 8) contributed secondary analyses of data in Chapters 6 and 7 exploring novel factors in enhanced clinical outcomes of non-surgical treatment of Morton’s neuroma using descriptive multivariate modelling and discriminant analysis. Method The thesis’s primary study (Chapters 6 and 7) featured an exploratory, pragmatic randomised controlled trial was designed to investigate the efficacy of an acute, short dosage (6, weekly episodes) of physiologically-principled manipulations, featuring discrete, high-velocity thrusting manoeuvres for treating Morton’s Neuroma. Adults electing treatment for Morton’s neuroma were randomly allocated to manipulative therapy (n = 29) or corticosteroid injection (n = 32). Baseline and follow-up (at 1·5, 3, 6, 9 and 12 months following treatment cessation) outcome measures of self-reported pain levels (VAS), pressure testing for discomfort thresholds (PTT) and functionality (walking and standing [MOxFQws], pain [MOxFQp)] and social interaction [MOxFQsi]; activities of daily living [FAAMdl], sports participation [FAAMspt] and general health [SF-36 PCS & MCS]) were measured ipsilaterally and by inventory. Results Chapters 6 and 7 showed that manipulation elicited substantive gains immediately after intervention (VAS [Cohen’s d, 3·3; 84·4%]; PTT [d, 2·3; 147·0%]; MOxFQws [d, 1·4; 52·8%]; MOxFQp [d, 1·3; 45·5%]; MOxFQsi [d, 0·9; 39·2%]) or accumulated during follow-up (FAAMdl [d, 2·2; 40·8%]; FAAMspt [d, 1·5; 66·1%]). Concomitant gains interactively for control participants were modest (d, 0·4 to 1·0; 16·6% to 45·9%) (p < 0·05 to p < 0·0005). Retention of improvements following manipulation cessation was substantial for all metrics, significantly better than baseline scores (VAS, PTT, MOxFQws, MOxFQp, MOxFQsi, FAAMdl, FAAMspt, SF-36 PCS and SF-36 MCS [d, 1·1 to 3·4; 40·8% to 152·3%]) and consistently exceeded that for corticosteroid injection (p < 0·01 to p < 0·001). Group mean intra-session and inter-day variability (V%) of PTT (Chapter 5) ranged between 6.8% and 13.6% for experienced and inexperienced test administrators, respectively, and suggested compromised precision amongst serial measurements of PTT over extended periods of time. Within Chapter 8, predictive multivariate modelling showed that in internal classification analyses, 88.9% of patients could be assigned correctly to high- and low-responders to treatment. Conclusion (i) Manipulation elicited significant and clinically relevant improvements and retention in self-reported levels of pain, discomfort and functionality for patients electing treatment for Morton’s neuroma; (ii) Exploratory multivariate modelling provided a significant prediction model for successful non-surgical treatment outcomes; (iii) Single measurements showed compromised precision amongst serial assessments of PTT