Arthrodesis of the first metatarsophalangeal joint:The“when and how”

Arthrodesis of the first metatarsophalangeal(MTP)joint has been established as the“gold standard”for the treatment of several first ray disorders,due to its perceived efficacy and the consistently reported good results in the literature.Arthrodesis is a commonly performed procedure for the treatment of end stage arthritis,rheumatoid arthritis with severe deformity,selected cases of severe hallux valgus(with or without signs of degenerative joint disease),as well as a salvage procedure after failed previous operation of the first ray.The goals of a successful 1st MTP arthrodesis are pain alleviation and deformity correction in order to restore a comfortable gait pattern and to improve shoe wear.Several techniques have been reported with several proposals regarding the preparation of the articular surfaces and the method of definitive fixation.As with any given surgical procedure,various complications may occur after arthrodesis of the 1st MTP joint,namely delayed union,nonunion,malunion,irritating hardware,etc.

First Metatarsophalangeal Joint Arthrodesis: Comparison of Mesenchymal Stem Cell Allograft versus Autogenous Bone Graft Fusion Rates

With patients undergoing first time 1st metatarsophalangeal joint arthrodesis using graft material when it was required to fill cystic bone voids, we retrospectively compared the time to fusion (clinical and radiographic), and non-union rate between the patient’s own bone autograft (n = 62) versus a mesenchymal stem cell impregnated allograft group (n = 51). A third control group (n = 52) was included in which an end-to-end arthrodesis was performed and no graft interposition was used or necessary. The non-union rate was 4% (n = 2) in the control group, 5.9% (n = 4) in the autograft group, and 9.5% (n = 5) in the mesenchymal stem cell allograft group. The time for radiographic fusion was 6.46 weeks for the control group, 6.52 weeks for the autograft group, and 6.53 weeks for the mesenchymal stem cell allograft group. The difference in time to clinical and radiographic union and the non-union rate were not found to be statistically significant among all 3 groups. Patient comorbidities and their possible effects on union rates were also analyzed within the populations. Some comorbidities had statistically significantly non-unions within the population, notably smoking (p = 0.024) and Rheumatoid arthritis (p = 0.001), however the populations were fairly small. The use of allogeneic bone graft impregnated with mesenchymal stem cells yields a similar fusion rate as with the use of autologous bone graft harvested from the surrounding area. The allograft impregnated with mesenchymal stem cells is a viable alternative yielding similar results when local autogenous bone graft is not available, not obtainable, or conditions warrant its use.

Why and How Often Is Revision Surgery Necessary after First Metatarsophalangeal Joint Arthrodeses? A Cohort of 120 Consecutive Cases

Background: Little is known about the rate and reasons for revision after primary Metatarsophalangeal (MTP1) arthrodesis with the latest implants. While it is commonly assumed that nonunion accounts for most reoperations, we hypothesized that malposition is the leading cause of revision. The aim of this study was to determine the rate and reasons for revision after MTP1 arthrodesis using cup- and cone-reamers and the latest locking plate technology. Method: Between 2015 and 2017, 120 consecutive MTP1 fusions in 114 patients were performed with a low profile, pre-contoured titanium dorsal locking plate and a plantar metatarsophalangeal screw. The rate and reasons for revision within a minimum one-year follow-up period (average 16 months [12 - 26]) after index procedures were documented and analyzed. The revision was defined as any reoperation following the index procedure excluding hardware removal. Results: Seventeen of 120 feet (14%) underwent revision. Four patients developed a nonunion (3.3%) and needed revision, and 11 feet (9%) required revision for painful malposition;insufficient extension and excessive valgus accounted for the majority. Two patients required medial sesamoidectomy. No infection or wound healing problems occurred. Twelve patients requested hardware removal. Conclusions: Nonunion revision rate after MTP1 fusion with the latest locking plate technology is low. The leading cause of revision is malposition followed by nonunion. Excessive valgus and insufficient extension account for most symptomatic malposition. A recommendation of 0 - 10 degrees of valgus in the horizontal plane may contribute to diminishing revision rates;no conclusions could be drawn regarding an optimal position in the sagittal plane.

Hallux rigidus: Joint preserving alternatives to arthrodesis- a review of the literature

Hallux rigidus describes the osteoarthritis of the firstmetatarsophalangeal joint. It was first mentioned in 1887. Since then a multitude of terms have been introduced referring to the same disease. The main complaints are pain especially during movement and a limited range of motion. Radiographically the typical signs of osteoarthritis can be observed starting at the dorsal portion of the joint. Numerous classifications make the comparison of the different studies difficult. If non-operative treatment fails to resolve the symptoms operative treatment is indicated. The most studied procedure with reproducible results is the arthrodesis. Nevertheless, many patients refuse this treatment option, favouring a procedure preserving motion. Different motion preserving and joint sacrificing operations such as arthroplasty are available. In this review we focus on motion and joint preserving procedures. Numer-ous joint preserving osteotomies have been described. Most of them try to relocate the viable plantar cartilage more dorsally, to decompress the joint and to increase dorsiflexion of the first metatarsal bone. Multiple studies are available investigating these procedures. Most of them suffer from low quality, short follow up and small patient numbers. Consequently the grade of recommendation is low. Nonetheless, joint preserving procedures are appealing because if they fail to relief the symptoms an arthrodesis or arthroplasty can still be performed thereafter.

Achieving high union rates after first metatarsophalangeal joint arthrodesis:Radiographic outcomes and technical pitfalls

BACKGROUND Fusion of the first metatarsophalangeal(MTP1)joint is a common surgery performed to correct hallux rigidus,hallux rigidus et valgus and other painful degenerative diseases of the MTP1.AIM To assess outcomes of our surgical technique including non-union rates,accuracy and aims of correction.METHODS Between September 2011 and November 2020 a total 72 of MTP1 fusions were performed using a low profile,pre-contoured dorsal locking plate and a plantar compression screw.Union and revision rates were analyzed with a minimum clinical and radiological follow up of at least 3 mo(range 3-18 mo).The following parameters were evaluated on pre-and postoperative conventional radiographs:Intermetatarsal angle,Hallux-valgus angle,dorsal extension of the proximal phalanx(P1)in relation to the floor and the angle between the Metatarsal 1 and the P1(MT1-P1 angle).Descriptive statistical analysis was performed.Pearson analysis was used to assess for correlations between radiographic parameters and achievement of fusion.RESULTS An overall union rate of 98.6%(71/72)was achieved.Two out of 72 patients did not primarily fuse with one patient suffering from a non-union,whilst the other demonstrating a radiological delayed union without clinical symptoms,with eventually complete fusion after 18 mo.There was no correlation between the measured radiographic parameters and the achievement of fusion.We believe the reason for the non-union was mainly attributed to the patient’s incompliance without wearing the therapeutic shoe leading to a fracture of the P1.Furthermore,we didn`t find any correlation between fusion and the degree of correction.CONCLUSION With our surgical technique,high union rates(98%)can be achieved using a compression screw and a dorsal variable-angle locking plate to treat degenerative diseases of the MTP1.

The Human Ankle-Foot Complex as a Multi-Configurable Mechanism during the Stance Phase of Walking

The objective of this study is to investigate the biomechanical functions of the human ankle-toot complex during the stancephase of walking. The three-dimensional (3D) gait measurement was conducted by using a 3D infrared multi-camera system anda force plate array to record the Ground Reaction Forces (GRF) and segmental motions simultaneously. The ankle-foot complexwas modelled as a four-segment system, connected by three joints: talocrural joint, sub-talar joint and metatarsophalangeal joint.The subject-specific joint orientations and locations were determined using a functional joint method based on the particleswarm optimisation algorithm. The GRF moment arms and joint moments acting around the talocrural and sub-talar joints werecalculated over the entire stance phase. The estimated talocrural and sub-talar joint locations show noticeable obliquity. Thekinematic and kinetic results strongly suggest that the human ankle-foot complex works as a mechanical mechanism with twodifferent configurations in stance phase of walking. These lead to a significant decrease in the GRF moment arms therebyincreasing the effective mechanical advantages of the ankle plantarflexor muscles. This reconfigurable mechanism enhancesmuscle effectiveness during locomotion by modulating the gear ratio of the ankle plantarflexor muscles in stance. This studyalso reveals many factors may contribute to the locomotor function of the human ankle-foot complex, which include not only itsre-configurable structure, but also its obliquely arranged joints, the characteristic heel-to-toe Centre of Pressure (COP) motionand also the medially acting GRF pattern. Although the human ankle-foot structure is immensely complex, it seems that itsconfiguration and each constitutive component are well tuned to maximise locomotor efficiency and also to minimise risk ofinjury. This result would advance our understanding of the locomotor function of the ankle-foot complex, and also the intrinsicdesign of the ankle-foot musculoskeletal structure. Moreover, this may also provide implications for the design of bionicprosthetic devices and the development of humanoid robots.

Metallic resurfacing hemiarthroplasty of the first metatarsophalangeal joint combined with first metatarsal osteotomy for the treatment of hallux rigidus with hallux valgus in China

Hallux rigidus occurs mainly at the first metatarsophalangeal （MTP） joint,causing localized pain and degenerative arthritis.1 This condition frequently occurs together with hallux valgus and is difficult to treat.For hallux rigidus affecting only one joint,the treatment choices include articular debridement,resection arthroplasty,prosthetic arthroplasty,and arthrodesis,depending on the degree of arthritis.

超声评估类风湿关节炎患者手和前足滑膜炎的相关性

目的:通过对类风湿关节炎患者手部及足部关节进行超声检查,结合临床指标,预测类风湿关节炎患者前足滑膜炎存在的相关因素,便于临床医师关注病情变化,及时调整治疗方案。方法:收集类风湿关节炎患者69例,对其均行二维和能量多普勒(PDUS)检查,并收集其临床指标。根据二维超声跖趾关节滑膜是否增厚将患者分为前足受累组19例和前足未受累组50例,对比2组之间临床指标和超声结果的差异,评估临床指标及手部关节超声结果与足部关节超声结果之间的相关性。结果:①前足受累组关节肿胀数(SJC)、患者的总体评估(PGA)、医师的总体评估(EGA)、DAS28评分、临床疾病活动度评分(CDAI)、手PDUS总分、手PDUS阳性关节数均明显高于前足未受累组,差异有统计学意义(P<0.05)。②前足PDUS阳性关节数与SJC、DAS28评分、CDAI间存在低度相关,与手PDUS总分之间存在显著相关(P<0.05)。③单因素变量回归分析显示,SJC、PGA、EGA、DAS28评分、手PDUS总分、手PDUS阳性关节数均是前足滑膜炎的危险因素(P<0.05)。多因素变量回归分析显示,只有手PDUS总分是前足滑膜炎的独立危险因素(P<0.05)。④类风湿关节炎患者手PDUS评分的受试者工作特征曲线(ROC)提示,当手总PDUS评分>5分时与跖趾关节滑膜炎有关,敏感性为90%,特异性为78%,提示手部PDUS评分与跖趾关节滑膜炎存在相关性。结论:手PDUS总分对于提示类风湿关节炎患者跖趾关节滑膜炎的存在具有很好的价值。

结合局部熵与梯度能量的双通道医学图像融合

多模态医学图像融合已成为有效结合正常组织结构和异常改变信息、提高医学诊断效率的强有力辅助技术.针对空域融合技术在处理图像细节丢失、光谱退化等方面的缺陷,提出一种在联合双边滤波器(JBF)域内实现图像结构与细节信息增强的双通道频域多模态医学图像融合方法.该方法将源图像分解为结构和能量2个通道,分别处理图像纹理细节信息和边缘强度信息.在结构通道中,通过改进梯度能量得到局部梯度能量算子,进一步提升融合图像对小尺度细节信息的表达能力和对噪声的鲁棒性;在能量通道中,利用非下采样轮廓波变换提高模型的多方向多尺度特性,并提出一种局部熵细节增强算子和脉冲耦合神经网络结合的高频子带处理框架,达到增强能量通道中结构信息和细节信息的效果.在Atlas公开数据集上,与基于MST、稀疏表示、PCNN以及JBF的6种具有代表性的频域融合方法进行对比及消融实验的结果表明,所提方法的融合图像与源图像相似度提升35.0%,空间频率提升16.2%,边缘保持度提升12.5%,对比度提升11.2%;并在视觉方面有较好的效果,明显优于对比方法.

掌骨锁定钢板在拇外翻第一跖趾关节融合术中的应用效果

目的:分析掌骨锁定钢板在拇外翻第一跖趾关节融合术中的应用效果。方法:回顾性分析瑞金市人民医院2019年5月—2021年5月收治的30例中重度拇外翻患者的病历资料,根据手术方案分为对照组与研究组,每组15例。对照组应用传统跖趾关节融合钢板治疗,研究组应用掌骨锁定钢板治疗。比较两组术前及末次随访的拇外翻角(hallux valgus angle,HVA)、跖骨间角(inter metatarsal angle,IMA)、美国矫形足踝协会前足功能评分(American orthopedic foot and ankle society,AOFAS)及视觉模拟评分法(visual analogue scale,VAS)评分;比较两组不良反应发生情况。结果:两组术后VAS评分、AOFAS评分、HVA及IMA均优于术前(P<0.05);研究组术后VAS、AOFAS评分及HVA、IMA均优于对照组,差异均有统计学意义(P<0.05);研究组并发症发生率虽低于对照组,但差异无统计学意义(χ^(2)=0.745,P>0.05)。结论:在中重度拇外翻患者行第一跖趾关节融合术中,应用掌骨锁定钢板在临床疗效上更优于传统钢板治疗,有助于促进骨的结构和功能恢复。

Outcomes following minimally invasive dorsal cheilectomy for hallux rigidus:A systematic review

BACKGROUND Cheilectomy of the 1^(st)metatarsophalangeal joint(MTPJ)is one of the most common procedures for the management of hallux rigidus.However,there is no consensus regarding outcomes following minimally invasive dorsal cheilectomy(MIDC)for the management of hallux rigidus.AIM To evaluate outcomes following MIDC for the management of hallux rigidus.METHODS During November 2023,the PubMed,EMBASE and Cochrane Library databases were systematically reviewed to identify clinical studies examining outcomes following MIDC for the management of hallux rigidus.RESULTS Six studies were included.In total,348 patients(370 feet)underwent MIDC for hallux rigidus at a weighted mean follow-up of 37.9±16.5 months.The distribution of patients by Coughlin and Shurna's classification was recorded in 4 studies as follows:Ⅰ(58 patients,27.1%),Ⅱ(112 patients,52.3%),Ⅲ(44 patients,20.6%).Three studies performed an additional 1^(st)MTPJ arthroscopy and debridement following MIDC.Retained intra-articular bone debris was observed in 100%of patients in 1 study.The weighted mean American orthopedic foot and ankle society score improved from a preoperative score of 68.9±3.2 to a postoperative score of 87.1.The complication rate was 8.4%,the most common of which was persistent joint pain and stiffness.Thirty-two failures(8.7%)were observed.Thirty-three secondary procedures(8.9%)were performed at a weighted mean time of 8.6±3.2 months following the index procedure.CONCLUSION This systematic review demonstrated improvements in subjective clinical outcomes together with a moderate complication rate following MIDC for the management of hallux rigidus at short-term follow-up.A moderate reoperation rate at short-term follow-up was recorded.The marked heterogeneity between included studies and paucity of high quality comparative studies limits the generation of any robust conclusions.

慢跑状态下人体第一跖趾关节受裸足或着鞋的影响差异研究

邀请20位健康男性业余长跑爱好者为研究对象,通过双平面高速荧光成像系统获取研究对象在裸足及着鞋状态下进行慢跑时的第一跖趾关节六自由度运动学参数,对比后得到不同状态下研究对象第一跖趾关节蹬伸效果和拇指外翻风险差异。结果表明:与裸足时相比,研究对象穿着慢跑鞋进行慢跑时的第一跖趾关节蹬伸效果受限明显,出现拇指外翻风险更高。

足趾关节移植重建手指关节的应用解剖

在手术显微镜下解剖观察了２０侧成人第２、３跖趾关节和近侧趾间关节的结构、动脉供应和神经支配。根据关节的结构特点，提出了供体关节的解剖学方法，移植关节动力系统和稳定系统的建立方法。每个关节有关节囊支、髁支干骺支三种动脉分支分布。跖址关节移植时可采用足背动脉一第１跖背动脉、大隐静脉一第１跖背静脉作为血管带，近侧趾间关节移植则利用趾底动脉或趾底固有动脉、趾背静脉作血管蒂。神经蒂选用趾背神经或趾底神经。

超声引导腘窝上坐骨神经联合隐神经阻滞在拇外翻合并跖趾关节脱位手术的临床观察

目的 :探讨超声引导腘窝上坐骨神经联合隐神经阻滞在前足矫形手术中的临床疗效。方法 :自2017年1月至2017年10月,将60例拇外翻合并跖趾关节脱位需要手术治疗的患者,采用随机数字表法分为试验组和对照组。试验组30例采用超声引导腘窝上坐骨神经联合隐神经阻滞,其中男13例,女17例,年龄31～76(59.23±10.07)岁;体重指数为21～30(24.57±1.85) kg/m^2;ASA分级:Ⅰ级12例,Ⅱ级18例。对照组30例采用单次腰麻,其中男12例,女18例,年龄20～74(54.20±15.87)岁;体重指数为20～29(24.43±3.15) kg/m^2;ASA分级:Ⅰ级11例,Ⅱ级19例。观察两组患者麻醉的阻滞时间、感觉神经阻滞起效时间、运动神经阻滞起效时间、运动神经经阻滞失效时间、感觉神经阻滞失效时间;比较阻滞前(T_0),阻滞后15 min(T_1),阻滞后30 min(T_2),手术开始时(T_3),手术开始后30 min(T_4),术毕(T_5)的血流动力学变化,观察患者的不良反应情况及主观满意度。结果:两种麻醉方案均获得满意的临床效果。试验组的麻醉阻滞时间、感觉神经阻滞起效时间、运动神经阻滞失效时间、感觉神经阻滞失效时间长于对照组,差异有统计学意义(P<0.001);两组的运动神经阻滞起效时间相比,差异无统计学意义(P>0.05)。试验组麻醉后各时间点的收缩压(SBP)、舒张压(DBP)和心率(HR)与阻滞前(T_0)相比,差异无统计学意义(P>0.05);对照组麻醉后各时间点的收缩压(SBP)、舒张压(DBP)与阻滞前(T_0)相比,差异有统计学意义(P<0.05);心率(HR)与阻滞前(T_0)相比,差异无统计学意义(P>0.05)。结论:超声引导腘窝上坐骨神经联合隐神经阻滞能够满足拇外翻及前足疾病手术的需求,维持血流动力学平稳,同时可有效延长术后镇痛时间,并且膝关节以上部位可以自由活动,提高了患者的整体舒适度及安全性。

改良跖趾关节游离移植重建掌指关节的显微解剖及临床应用

目的:为带血供改良跖趾关节全关节及半关节移植修复掌指关节的应用提供解剖学基础,总结该改良关节置换不同术式的临床应用经验。方法:解剖观测30侧经动脉内灌注红乳胶成尸下肢标本,对第2跖趾关节的解剖结构及血供关系进行显微解剖学测量。在解剖学研究的基础上,临床应用吻合血管的改良全关节及半关节重建修复掌指关节14例,其中全关节8例,半关节6例。术后均进行早期系统的康复训练。结果:第2跖趾关节的血供丰富,血管、神经位置恒定。临床应用14例,其中12例于术后5个月～3年2个月得到随访,第2掌指关节均获得较良好的功能恢复,带关节囊半关节移植效果最佳,全关节移植次之。结论:改良的第2跖趾关节游离移植重建第2掌指关节的不同术式,能有效地恢复第2掌指关节的功能。熟悉关节的解剖特点、改良的手术方案、神经关节支的修复及全面的关节结构功能重建是手术的关键。

慢跑鞋前掌屈曲刚度对男性跑者的跑步经济性及下肢关节功的影响

目的:探讨慢跑鞋前掌屈曲刚度对男性跑者的跑步经济性及下肢关节功的影响。方法:通过改变中底凹槽的密度和深度制作5双不同屈曲刚度的慢跑鞋(A、B、C、D、E鞋的屈曲刚度依次减小),分析11名男性跑者分别穿这5种鞋跑时的耗氧量及下肢关节做功。结果:慢跑鞋前掌屈曲刚度对男性跑者跑步经济性及慢跑支撑阶段跖趾关节的正功、负功表现出统计学差异,但对髋、膝、踝关节的机械功差异无统计学意义,中等屈曲刚度的跑鞋跖趾关节机械功与耗氧量均表现为最低,屈曲刚度最大和最小的跑鞋较高。结论:慢跑鞋前掌屈曲刚度对男性跑者的跑步经济性及跖趾关节机械功的影响呈现先减小后增大的趋势,刚度过大和过小的跑鞋均会增大跖趾关节的机械功,降低跑步经济性。慢跑鞋前掌屈曲刚度对男性跑者跖趾关节机械功的影响可能是其影响跑步经济性的原因。

Swanson人工跖趾关节置换治疗Freiberg病近期疗效观察

目的:观察Swanson人工跖趾关节置换治疗晚期Freiberg病近期疗效。方法:2006年7月至2007年12月应用Swanson人工关节假体实施跖趾关节置换手术治疗晚期Freiberg病13例(18足),其中男1例(1足),女12例(17足)。合并母外翻12例(17足),创伤性关节炎1例(1足)。病变均为第2跖趾关节。X线参照Smillie分期,所有患足均为晚期,其中4期11足,5期7足。采用美国足踝外科协会AOFAS评分系统对手术前后疼痛、行走、穿鞋及跖趾关节活动度等进行临床评价。随访时间3～17个月,平均11.3个月。结果:所有病例术后关节疼痛明显改善,活动度改善。术前AOFAS评分平均为(50.06±9.59)分,术后平均为(77.50±4.99)分,术后与术前AOFAS评分相比,差异有统计学意义(P<0.05)。结论:Swanson人工跖趾关节置换术治疗晚期Freiberg病近期疗效满意,能明显改善关节活动度及疼痛,是一种较为可行的术式。

人体跖趾关节弯曲对行走步态特征的影响

目的 :研究人体跖趾关节弯曲对步态特征的影响 ,在该关节运动受约束后 ,其它关节的补偿方式。方法 :5个健康男性志愿者参加了实验 ,分别就正常情况和跖趾关节运动受到约束时的自然步态特征从实验的角度进行了研究。结果 :在跖趾关节运动受到约束后 ,人体其它关节角位移峰 -峰值和角速度峰 -峰值均有明显变化。结论 :为实现由于跖趾关节受到约束后的协调行走 ,人体其它关节会有相应的补偿运动 ,而且是通过多关节的协调运动来进行的。但各关节对协调运动的贡献大小是不同的。通过实验可知 ,运动补偿主要发生在踝关节和膝关节 ,同时上躯干也加入到补偿之中。由于多关节协调运动补偿 ,人体在跖趾关节运动受到约束后 ,其自然行走步态的平均步速和步长可达到正常情况的 94.8%和 95 .5 %。

第1跖趾关节及趾趾间关节的血供特点及其临床意义

目的：弄清第１跖趾关节和趾趾间关节的血供。方法：正常动脉灌注红色乳胶成人足２４只，观测第１跖趾关节和趾趾间关节的结构，各关节血管及神经的分布情况。结果：第１跖趾关节的动脉关节支来源于第１跖背动脉、第１跖底动脉以及它们的分支趾趾背动脉、趾底动脉和横动脉。它有背胫侧、背腓侧、跖胫侧、跖腓侧、关节前和关节后６部分关节支。趾趾间关节的动脉关节支来源于趾趾背动脉、趾底动脉和横动脉。它有背胫侧、背腓侧、跖胫侧、跖腓侧和关节后５部分关节支。结论：第１跖趾关节和趾趾间关节的血供丰富，但跖侧多于背侧，腓侧多于胫侧，故这些部位手术时，切口尽可能在背胫侧，以减少对关节血供的影响。