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

Third-Generation Percutaneous Forefoot Surgery

Hallux valgus is one of the most common diseases that affects the foot. The primary symptom of this disease is usually pain. Although non-operative treatment should be attempted, some patients eventually need surgical treatment. There are numerous surgical procedures for correction of HV deformities. Some of these surgeries may be performed through open or percutaneous surgery (MIS). Distal metatarsal chevron osteotomy is an excellent treatment option in mild-to-moderate deformities, providing good results in the correction of deformities and symptoms. This technique can also be done by percutaneous or MIS surgeries; the set of these surgeries are called Third generation procedures. They have been showed to be useful, effective and (maybe) easier than open procedures

A constituição democrática: entre o neoconstitucionalismo e o novo constitucionalismo

Neoconstitucionalismo e novo constitucionalismo são dois termos muitas vezes usados como sinônimos. Entretanto, tanto em sua origem quanto em seu conceito são categorias diferentes, pensadas para situações distintas. O neoconstitucionalismo é uma categoria analítica que busca criar uma teoria do direito e, secundariamente, explicar as faculdades do juiz ordinário como intérprete da Constituição. O novo constitucionalismo surge a partir da experiência das novas constituições latino-americanas, tendo como marco a Carta Constitucional colombiana de 1991, e enfatiza a legitimidade democrática da Constituição. Neoconstitucionalismo e novo constitutucionalismo são conceitos não necessariamente complementares, embora possam coincidir em determinados aspectos, como no que se refere à centralidade da supremacia constitucional ou à constitucionalização do ordenamento jurídic

An anatomical study of nerves at risk during minimally invasive hallux valgus surgery

The growing popularity of minimally invasive surgical (MIS) procedures makes it necessary that new anatomical references arise, to aid in tridimensional orientation and localization of structures that are not directly visible to the surgeon. This is especially critical for structures at risk like nerves or blood vessels. Optimization of the handling of cadaveric material and the combination of multiple techniques compensate for the limited availability of adequate specimens. The described protocol combines anatomical plane-by-plane dissection and sectional anatomy of fresh-frozen specimens to help localize relevant structures, such as nerves, arteries, veins and to correctly position the portals during MIS procedures. Depiction of these structures in anatomy textbooks can differ from what is encountered in the surgical field; and for this reason, new anatomical studies with a surgical orientation are needed. However, this is a complex, time-consuming technique requiring specific training. The anatomical references described with the so-called 'clock method' provide the surgeon with an easy and reproducible system to locate the path of the nerves at risk in Hallux Valgus MIS procedures. This model can be extrapolated to many other minimally invasive surgical procedures

Body donation, teaching and research in dissection rooms in Spain in times of Covid-19

The state of alarm due to Covid-19 pandemic in Spain stopped all educational and most university research activities. The Spanish Anatomical Society (SAE) Consensus Expert Group on Body Donations piloted a study based on a questionnaire to know the status of body donations and dissection activities during the lockdown, as well as the future implications of Covid-19 pandemic for body donation programs and Anatomy teaching. The questionnaire results show that Spanish Universities refused body donations and stopped all dissection research and teaching. The Covid-19 expected influence on Anatomy teaching was referred to the increase of teaching workforce and resources required to apply the new safety measures to future practical activities, as well as to prepare and adapt teaching material for online-only programs. The application of reinforced safety measures was expected to be perceived by the respondent's students as a gain in teaching quality, while the transformation of the anatomy courses in online-only programs will be perceived as a quality decrease. The respondent's concerns about future institutional implications of the pandemic were related to increased costs of the adaptation of the facilities and the reinforced preventive measures, as well as the eventual decrease in donations. The complete lockdown applied on dissection rooms is not justified by scientific evidence and represents a break of the confidence deposed in the institutions by the donors. A consensus is required for the adoption of a renewed, comprehensive protocol for present and future body donations including the evidence Covid-19 pandemic has contributed to create

Implantation of a Cushioning Injectable Implant Using Needle Arthroscopy in the Foot and Ankle and First Carpometacarpal Joint

Injectable implants constitute a newly developed treatment class in the battle against osteoarthritis. They consist of water-formulated supramolecular polymer, coming from a new class of resorbable biomedical materials, and are implanted in encapsulated joints in a liquid form, where they solidify to form a tough, elastic, and cushioning layer between the joint surfaces. To resort any effect, intra-articular delivery should be guaranteed, and the implant should be distributed throughout the entire joint space. Traditional implantation techniques do not seem to suffice for this new implant class, being either imprecise (traditional injection) or overly invasive (open procedures and traditional arthroscopic surgery). We describe a needle arthroscopic implantation technique to reap the benefits of both worlds, ensuring precise implant delivery while avoiding unnecessarily invasive procedures. This study depicts our needle arthroscopic technique for implantation of injectable implants in the ankle, first metatarsophalangeal joint, and first carpometacarpal joint.</p

Increasing the safety of minimally invasive hallux surgery: an anatomical study introducing the clock method

Background: the purpose of this study is to describe a simple and reproducible method to localize the neurological structures at risk and to describe a safe zone for hallux minimally invasive surgery (MIS) procedures. Methods: ten fresh-frozen cadaveric feet were dissected to identify the dorsomedial digital nerve (DMDN) and the dorsolateral digital nerve (DLDN) of the first toe. Axial sections were performed at the sites of metatarsal osteotomies. We documented the position of the nerves with respect to the extensor hallucis longus (EHL) tendon using a clock method superimposed on the axial section. Results: the DMDN was found at an average of 26.2° medial to the medial border of the EHL tendon. (SD 11.26, range 14.5-45.5), whereas the average distance of the DLDN was 32.3° lateral to the medial border of the EHL tendon. (SD 6.29, range 13.5-40). Conclusions: using the clock method the DMDN and DLDN were found consistently between 10 o'clock and 2 o'clock in either right and left feet. The clock method may facilitate avoiding the area where these nerves are located serving as a valuable tool in minimally invasive foot surgery

Anatomy of the inferior extensor retinaculum and its role in lateral ankle ligament reconstruction: a pictorial essay

The inferior extensor retinaculum (IER) is an aponeurotic structure, which is in continuation with the anterior part of the sural fascia. The IER has often been used to augment the reconstruction of the lateral ankle ligaments, for instance in the Broström-Gould procedure, with good outcomes reported. However, its anatomy has not been described in detail and only a few studies are available on this structure. The presence of a non-constant oblique supero-lateral band appears to be important. This structure defines whether the augmentation of the lateral ankle ligaments reconstruction is performed using true IER or only the anterior part of the sural fascia. It is concluded that the use of this structure will have an impact on the resulting ankle stability

Wildland–urban interface fires in spain: summary of the policy framework and recommendations for improvement

Southern Europe is recurrently being hit by forest fires affecting wildland–urban interface (WUI) areas which, particularly in the last decade, have resulted in tremendous consequences. In the years to come, self-protection of communities will be a first priority over fire suppression, demanding better fire-resistant and resilient WUI scenarios through actions grounded on solid and sound regulations and legislation. As of today, the European Union as a whole, and the Member States in particular, are belatedly articulating new and appropriate regulations and implementing policies for the protection of WUI areas against forest fires. Spain is one of the EU Member States, holding 1.1 million ha of WUI areas (above 4% of the total forested land) and experiencing an average of 12,500 forest fires per year over the past decade. In this paper a review of the state of the art on regulations, codes, plans and recommendations on WUI fire prevention and management in Spain is presented. Shortcomings due to the current lack of building and urban planning standards and technical codes for WUI communities are highlighted. We underline some paramount needs to be covered by scientific research and fire engineering in particular topics. Some of them have received little attention in the literature related to European WUI fires while some others have been almost unexplored, such as planning of low-fuel fringes, design of road networks and accessibility, dimension of water supply networks, study of ignitability and combustibility of residential vegetation, role of construction methods and materials, and the wildland–industrial interface. Outcomes from research activities on such topics should lead to appropriately drive and inform the policy making processes on WUI fire prevention and management in Spain and, by extension, in other southern European countries under a similar situation.Postprint (author's final draft

Characterization of a bipartite medial cuneiform: micro-CT and anatomical study

A bipartite medial cuneiform is an anatomical variant consisting in a horizontal division of the bone. Previous descriptions of the joint type, obtained from archaeological material or clinical reports, are unclear. This study was conducted in a fresh-frozen left foot, which allowed studying the morphology of the ligaments after anatomical dissection. In addition a Micro-CT analysis was performed to elucidate the osseous structure supporting the articular surfaces. A complex ligamentous system was found between the two halves of the bipartite medial cuneiform. Two articular surfaces were observed between the two components. Hyaline cartilage was observed at the posterior surface, while fibrous tissue was found at the anterior surface. Micro-CT analysis revealed different osseous structures for each articular surface, thus proving the existence of two joint types. The finding of a bipartite medial cuneiform in a fresh-frozen specimen allowed us to perform an analysis of the soft-tissues and articular surfaces that shows the presence of hyaline cartilage and articular ligaments in the diarthrodial joint as well as the fibrous component of the synfibrosis. Micro-CT analysis further reinforces our morphological findings. Our results prove that two different joint types exist, which could help explaining the disparity of descriptions in the literature