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Foot & Ankle International Jan 2022Hallux valgus is a multiplanar deformity that is often treated on the basis of 2-dimensional (2D) parameters and radiographs. Recurrence rates after surgical correction...
BACKGROUND
Hallux valgus is a multiplanar deformity that is often treated on the basis of 2-dimensional (2D) parameters and radiographs. Recurrence rates after surgical correction remain high, and failure to correct pronation of the metatarsal is increasingly stipulated as being part of the problem. Multiple methods of assessing metatarsal pronation have been proposed.
METHODS
We performed a systematic literature review identifying studies that measured metatarsal pronation and torsion on computed tomography (CT) scans. Specific methodology, patient groups, results, and reliability assessments were all reported.
RESULTS
We identified 14 studies that fulfilled the inclusion criteria. Eleven studies measured 2D values on CT scan, and 3 studies used computer-based 3-dimensional (3D) modeling and artificial intelligence systems to help calculate pronation. Metatarsal pronation angle, α angle, sesamoid rotation angle, and measurements for torsion were the most commonly used methods. All angles and measurements were performed as 2D measurements, but the metatarsal pronation angle was also performed with 3D modeling. Reliability and reproducibility of the α angle and metatarsal pronation angle were excellent, despite being performed on studies with small numbers.
CONCLUSION
Multiple methods have been reported to demonstrate first metatarsal pronation on CT, of which the α angle and the metatarsal pronation angle are the most pragmatic and useful in a clinical setting. Further work is needed to further validate the reliability of these measurements in larger series and to identify normal pronation and metatarsal torsion on weightbearing imaging. Further work is required to determine whether addressing pronation reduces recurrence rates and improves outcomes in surgery for hallux valgus.
LEVEL OF EVIDENCE
Level III, retrospective cohort study.
Topics: Artificial Intelligence; Hallux Valgus; Humans; Metatarsal Bones; Reproducibility of Results; Retrospective Studies; Rotation; Tomography, X-Ray Computed
PubMed: 34167335
DOI: 10.1177/10711007211020676 -
The American Journal of Sports Medicine Oct 2021Proximal fifth metatarsal fractures are among the most common forefoot injuries in athletes. The management of this injury can be challenging because of delayed union... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Proximal fifth metatarsal fractures are among the most common forefoot injuries in athletes. The management of this injury can be challenging because of delayed union and refractures. Intramedullary (IM) screw fixation rather than nonoperative management has been recommended in the athletic population.
PURPOSE
To provide an updated summary of the return-to-play (RTP) rate and time to RTP after Jones fractures in athletes with regard to their management, whether operative or nonoperative, and to explore the union rate and time to union as well as the rate of complications such as refractures.
STUDY DESIGN
Meta-analysis.
METHODS
Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, 2 independent team members searched several databases including PubMed, MEDLINE, Embase, Google Scholar, Web of Science, Cochrane Library, and ClinicalTrials.gov through November 2019 to identify studies reporting on Jones fractures of the fifth metatarsal exclusively in athletes. The primary outcomes were the RTP rate and time to RTP, whereas the secondary outcomes were the number of games missed, time to union, and union rate as well as the rates of nonunion, delayed union, and refractures.
RESULTS
Of 168 studies identified, 22 studies were eligible for meta-analysis with a total of 646 Jones fractures. The overall RTP rate was 98.4% (95% CI, 97.3%-99.4%) in 626 of 646 Jones fractures. The RTP rate with IM screw fixation only was 98.8% (95% CI, 97.8%-99.7%), with other surgical fixation methods (plate, Minifix) was 98.4% (95% CI, 95.8%-100.0%), and with nonoperative management was 71.6% (95% CI, 45.6%-97.6%). There were 3 studies directly comparing RTP rates with surgical versus nonoperative management, which showed significant superiority in favor of surgery (odds ratio, 0.033 [95% CI, 0.005-0.215]; < .001). The RTP rate according to type of sport was 99.0% (95% CI, 97.5%-100.0%) in football, 91.1% (95% CI, 82.2%-99.4%) in basketball, and 96.6% (95% CI, 92.6%-100.0%) in soccer. The overall time to RTP was 9.6 weeks (95% CI, 8.5-10.7 weeks). The time to RTP in the surgical group (IM screw fixation) was 9.6 weeks (95% CI, 8.3-10.9 weeks), which was significantly less than that in the nonoperative group of 13.1 weeks (95% CI, 8.2-18.0 weeks). The pooled union rate in the operative group (excluding refractures) was 97.3% (95% CI, 95.1%-99.4%), whereas the pooled union rate in the nonoperative group was 71.4% (95% CI, 49.1%-93.7%). The overall time to union was 9.1 weeks (95% CI, 7.7-10.4 weeks). The time to union with IM screw fixation (8.2 weeks [95% CI, 7.5-9.0 weeks]) was shorter than that with nonoperative treatment (13.7 weeks [95% CI, 12.7-14.6 weeks]). The rate of delayed union was 2.5% (95% CI, 1.2%-3.7%), and the overall refracture rate was 10.2% (95% CI, 5.9%-14.5%).
CONCLUSION
The RTP rate and time to RTP after the surgical management of Jones fractures in athletes were excellent, regardless of the implant used and type of sport. IM screw fixation was superior to nonoperative management, as it led to a higher rate of RTP, shorter time to RTP, higher rate of union, shorter time to union, and improved functional outcomes. We recommend surgical fixation for all Jones fractures in athletes.
Topics: Athletes; Fractures, Bone; Humans; Metatarsal Bones; Retrospective Studies; Return to Sport
PubMed: 33740393
DOI: 10.1177/0363546521990020 -
The American Journal of Sports Medicine Mar 2022While some studies have failed to reveal any significant relationship between magnetic resonance imaging (MRI) grading and return to sports after bone stress injuries,... (Meta-Analysis)
Meta-Analysis
BACKGROUND
While some studies have failed to reveal any significant relationship between magnetic resonance imaging (MRI) grading and return to sports after bone stress injuries, others have reported either a linear or nonlinear relationship.
PURPOSE
To evaluate the prognostic value of MRI grading for time to return to sports and rate of return to sports after bone stress injuries.
STUDY DESIGN
Systematic review and meta-analysis.
METHODS
A systematic search was performed in PubMed, Web of Science, SPORTDiscus, and Google Scholar. Studies reporting return to sports data after bone stress injuries using MRI grading systems were included in this review. The risk of bias was evaluated using the Quality in Prognosis Studies tool. Meta-analyses were performed to summarize the mean time to return to sports. The Pearson correlation was used to determine the relationship between time to return to sports and MRI grade. A meta-analysis of proportions was conducted to determine the percentage of athletes who successfully returned to sports.
RESULTS
A total of 16 studies with 560 bone stress injuries met inclusion criteria. Higher MRI-based grading was associated with an increased time to return to sports ( < .00001). Pooled data revealed that higher MRI-based grading correlated with a longer time to return to sports ( = 0.554; = .001). Combining all anatomic locations, the mean time to return to sports was 41.7 days (95% CI, 30.6-52.9), 70.1 days (95% CI, 46.9-93.3), 84.3 days (95% CI, 59.6-109.1), and 98.5 days (95% CI, 85.5-112.6) for grade 1, 2, 3, and 4 injuries, respectively. Trabecular-rich sites of injury (eg, pelvis, femoral neck, and calcaneus) took longer to heal than cortical-rich sites of injury (eg, tibia, metatarsal, and other long-bone sites of injury). Overall, more than 90% of all athletes successfully returned to sports.
CONCLUSION
The findings from this systematic review indicate that MRI grading may offer a prognostic value for time to return to sports after the nonsurgical treatment of bone stress injuries. Both MRI grade and location of injury suggest that individually adapted rehabilitation regimens and therapeutic decisions are required to optimize healing and a safe return to sports.
Topics: Athletes; Athletic Injuries; Fractures, Stress; Humans; Magnetic Resonance Imaging; Return to Sport; Sports
PubMed: 33720786
DOI: 10.1177/0363546521993807 -
European Journal of Orthopaedic Surgery... Oct 2021Metatarsal fractures are relatively common injuries that they might lead to significant disability and chronic pain if suboptimally treated. Operative treatment is... (Review)
Review
PURPOSE
Metatarsal fractures are relatively common injuries that they might lead to significant disability and chronic pain if suboptimally treated. Operative treatment is reserved for the displaced fractures. The primary aim of the herein study is to present the union time and rate, as well as the functional outcome of the surgically treated isolated lesser metatarsal shaft and neck fractures. The secondary aim is to present the related complications of each fixation method.
METHODS
The electronic databases of Pubmed, Scopus, Embase and Cochrane libraries were searched from January 1990 to December 2020. PRISMA guidelines were used for data collection. We retrieved five articles including in total 154 patients, which were compatible to our inclusion criteria and they were used for this systematic review.
RESULTS
A total of 75 patients were treated with percutaneous antegrade pinning resulting in AOFAS score: 96.4 ± 4.8 and time to heal 7.4 ± 1 weeks, 34 patients underwent ante/retrograde pinning resulting in AOFAS score: 95.2 ± 4.75 and time to heal 6.5 ± 1 weeks, and 45 patients underwent open reduction and internal fixation with plate and screws resulting in a time to union 10.9 ± 0.5 weeks.
CONCLUSION
Our results demonstrate that K wire intramedullary nailing regardless of the specific technique (antegrade, retrograde, ante/retrograde) is associated with better outcomes compared to open reduction and internal fixation as it permits faster weight bearing and quicker rehabilitation. K-wire fixation is related to statistically significant shorter time for the fracture to heal, by approximately three weeks compared to open reduction and internal fixation. Future research should focus on studies directly comparing the different intramedullary K-wiring techniques and also K-wiring versus plate fixation.
Topics: Bone Wires; Fracture Fixation, Intramedullary; Fractures, Bone; Humans; Metatarsal Bones; Treatment Outcome
PubMed: 33484346
DOI: 10.1007/s00590-020-02869-y -
Injury Dec 2020Approximately 75% of fractures are simple, stable injuries which are often unnecessarily immobilised with subsequent repeated radiographs at numerous fracture clinic...
AIMS
Approximately 75% of fractures are simple, stable injuries which are often unnecessarily immobilised with subsequent repeated radiographs at numerous fracture clinic visits. In 2014, the Glasgow Fracture Pathway offered an alternative virtual fracture clinic (VFC) pathway with the potential to reduce traditional fracture clinic visits, waiting times and overall costs. Many units have implemented this style of pathway in the non-operative management of simple, undisplaced fractures. This study aims to systematically review the clinical outcomes, patient reported outcomes and cost analyses for VFCs.
MATERIALS AND METHODS
Two independent reviewers performed the literature search based on PRISMA guidelines, utilizing the MEDLINE, EMBASE and COCHRANE Library databases. Studies reporting outcomes following the use of VFC were included. Outcomes analysed were: 1) clinical outcomes, 2) patient reported outcomes, and 3) cost analysis.
RESULTS
Overall, 15 studies involving 11,921 patients with a mean age of 41.1 years and mean follow-up of 12.6 months were included. In total, 65.7% of patients were directly virtually discharged with protocol derived conservative management, with 9.1% using the Helpline and 15.6% contacting their general practitioner for advice or reassurance. A total of 1.2% of patients experienced fracture non-unions and 0.4% required surgical intervention. The overall patient satisfaction rate was 81.0%, with only 1.3% experiencing residual pain at the fracture site. Additionally, the mean cost per patient for VFC was £71, with a mean saving of £53 when compared to traditional clinic models. Subgroup analysis found that for undisplaced fifth metatarsal or radial head/neck fractures, the rates of discharge from VFC to physiotherapy or general practitioners were 81.2% and 93.7% respectively.
DISCUSSION AND CONCLUSION
This study established that there is excellent evidence to support virtual fracture clinic for non-operative management of fifth metatarsal fractures, with moderate evidence for radial head and neck fractures. However, the routine use of virtual fracture clinics is presently not validated for all stable, undisplaced fracture patterns.
LEVEL OF EVIDENCE
IV; Systematic Review of all Levels of Evidence.
Topics: COVID-19; Communicable Disease Control; Cost-Benefit Analysis; Evidence-Based Medicine; Fractures, Bone; Humans; Orthopedics; Patient Satisfaction; Remote Consultation; Treatment Outcome
PubMed: 33162011
DOI: 10.1016/j.injury.2020.11.001 -
The Journal of Foot and Ankle Surgery :... 2021The optimal method of fixation of acute Lisfranc injuries is yet to be established. We aim to systematically review the literature to identify the impact of fixation... (Meta-Analysis)
Meta-Analysis Review
The optimal method of fixation of acute Lisfranc injuries is yet to be established. We aim to systematically review the literature to identify the impact of fixation method on postoperative functional outcomes. A systematic review was undertaken using the PRISMA framework to identify all studies reporting postoperative functional outcomes in patients who underwent open-reduction internal fixation of acute Lisfranc injuries. Studies reporting outcomes of numerous fixation methods were divided into fixation subcohorts. Studies comparing bridge plate with transarticular screw fixation were included for meta-analysis, conducted using a random-effects model. Seventeen studies (20 subcohorts) with 462 patients were included. Mean patient age was 29.6 (rang, 15-81) years. Mean follow-up was 38.7 (range 11 to 287) months. American Academy of Orthopaedic Surgeons midfoot score (AOFAS-MF) was the most frequently reported functional outcome (16/20 subcohorts). Overall weighted mean AOFAS-MF was 76.3 ± 9.4 for all cases, with 74.2 ± 9.4 for transarticular screws and 79.2 ± 8.3 for bridge plates. The mean difference between screw and plate was not statistically significant (mean difference = 5.0, 95% confidence interval, -4.8 - 14.8, p = .3). A single study reported AOFAS-MF mean of 92 using suture button fixation. Meta-analysis of the 2 available comparative studies revealed higher postoperative AOFAS-MF with bridge plate fixation (pooled standardized mean difference, 0.51; 95% confidence interval, 0.15-0.87, p = .006). There is scarcity of literature examining the impact of fixation method on postoperative functional outcomes in acute Lisfranc injuries. A small number of studies have reported superior functional outcomes with use of bridge plate fixation. Further evidence is needed to ascertain which injuries are best managed with each fixation method or whether 1 fixation construct is universally superior.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Bone Plates; Bone Screws; Fracture Fixation, Internal; Humans; Metatarsal Bones; Middle Aged; Open Fracture Reduction; Young Adult
PubMed: 33039319
DOI: 10.1053/j.jfas.2020.04.005 -
International Journal of Environmental... Sep 2020We aimed to synthesise the results of previous studies addressing the impact of overweight and obesity on plantar pressure in children and adolescents. An electronic...
We aimed to synthesise the results of previous studies addressing the impact of overweight and obesity on plantar pressure in children and adolescents. An electronic search of scientific literature was conducted using PubMed, Cochrane and Scopus database, with keywords: "plantar pressure" AND "children" AND "obesity"; "plantar pressure" AND "adolescents" AND "obesity", "plantar pressure" AND "children" AND "overweight", "plantar pressure" AND "adolescents" AND "overweight". Twenty-two articles were included in the review and the following data were recorded: authors, publication year, type of technology (systems, software) for the determination of plantar pressure, study characteristics. Most of the articles used dynamic plantar pressure determination with only four using static plantar pressure measurement. Using ultrasonography with static plantar pressure determination, the correlation between structural and functional changes in the feet of obese children. In overweight and obese children and adolescents, important findings were recorded: higher contact area, increased maximum force beneath the lateral and medial forefoot, increased pressure-time integral beneath the midfoot and 2nd-5th metatarsal regions. Significantly increased foot axis angle and significantly flatter feet were observed in obese subjects in comparison to their normal-weight counterparts. The obese children presented increased midfoot fat pad thickness, with decreased sensitivity of the whole foot and midfoot.
Topics: Adolescent; Body Mass Index; Child, Preschool; Female; Foot; Foot Bones; Humans; Male; Obesity; Overweight; Pressure; Ultrasonography
PubMed: 32927870
DOI: 10.3390/ijerph17186600 -
Foot and Ankle Surgery : Official... Aug 2021Freiberg's disease is an osteonecrosis of the metatarsal head bone. Numerous surgical interventions can be provided; however, the literature is limited in systematic... (Review)
Review
BACKGROUND
Freiberg's disease is an osteonecrosis of the metatarsal head bone. Numerous surgical interventions can be provided; however, the literature is limited in systematic reviews discussing the various options. The study aimed to systematically review the quantity and quality of literatures exploring the surgical interventions.
METHODS
Fifty articles were found to be relevant for assessing the efficacy of common surgical interventions. The articles were assigned a level of evidence (I-V) to assess their quality. Next, the studies were reviewed to provide a grade of recommendation (A-C, I).
RESULTS
Two studies were found at level III that explored osteotomy and autologous transplantation; the other studies were level IV-V. There is poor evidence (grade C) in supporting of joint sparing and joint sacrificing for Freiberg's disease.
CONCLUSION
Poor evidence exists to support the surgical interventions for Freiberg's disease, higher quality trials are needed to support the increasing application of these surgical techniques.
LEVEL OF EVIDENCE
Level IV, Systematic review.
Topics: Humans; Metatarsal Bones; Metatarsus; Osteochondritis
PubMed: 32917526
DOI: 10.1016/j.fas.2020.08.005 -
Foot and Ankle Surgery : Official... Aug 2021We reviewed the rates of and reasons for hallux valgus (HV) recurrence and the rates of avascular necrosis following Scarf osteotomy. (Review)
Review
BACKGROUND
We reviewed the rates of and reasons for hallux valgus (HV) recurrence and the rates of avascular necrosis following Scarf osteotomy.
METHODS
We searched the Cochrane Library, PubMed, and Embase databases for studies reporting operative management of HV using Scarf osteotomy. The primary endpoints were reasons for and rates of HV recurrence. The secondary endpoint was the rate of avascular necrosis.
RESULTS
We included 15 studies with 946 operations for HV. Seven studies reported no recurrence, six reported recurrence rates of 3.6-11.3%, one reported a recurrence rate of 30%, and one reported a recurrence rate of 78%. Thirteen studies (678 feet) reported other complications from Scarf osteotomy without avascular necrosis.
CONCLUSIONS
Although HV recurrence is not uncommon following Scarf osteotomy, patient-related factors, surgical competence, and longer follow-up are more likely to be associated with recurrence. Avascular necrosis is an infrequent complication in HV patients treated using Scarf osteotomy.
Topics: Bunion; Foot; Hallux Valgus; Humans; Metatarsal Bones; Osteonecrosis; Osteotomy; Treatment Outcome
PubMed: 32891491
DOI: 10.1016/j.fas.2020.08.009 -
Advances in Wound Care Feb 2021Diabetic foot ulcers (DFUs) are associated with high morbidity, mortality, and health costs. Standard care (SC) associated with nonsurgical offloading is the mainstay... (Meta-Analysis)
Meta-Analysis
Diabetic foot ulcers (DFUs) are associated with high morbidity, mortality, and health costs. Standard care (SC) associated with nonsurgical offloading is the mainstay treatment for DFUs, but it has high recurrence and infection rates. Metatarsal head resection (MHR) has been proposed as an effective surgical offloading technique for the treatment of plantar neuropathic DFUs, but with no evidence synthesis yet. Based on PRISMA guidelines, a meta-analysis was conducted to assess the efficacy of MHR. Four electronic databases were searched for. Eleven studies met the inclusion criteria with a total of 477 patients (494 feet and 593 neuropathic forefoot ulcers). The studies included three retrospective comparative studies and eight case series. Meta-analytical results of comparative studies on recent noninfected DFUs showed MHR having significantly better rates of healing, time to healing, ulcer recurrence, and infection than SC. Failure to heal, recurrence, and infection rates were 4 times higher in the SC group than in the MHR group, and the amputation rate was two times higher in the SC group than in the MHR group. The outcomes of the meta-analysis of case series on chronic and recalcitrant ulcers treated with MHR were similar. Considering the natural history of DFUs treated conservatively and the satisfactory outcomes with a significantly low complication rate of MHR, physicians should consider the use of MHR more often and include this technique in the early management of DFUs. DFU impose great public health burden around the globe. Standard of care using in-office debridement and topical agents is the usual mainstay of treatment. However, such conservative care is known to result in high rates of ulcer recurrence and complications. In this systematic review, we quantitatively investigate the outcomes of a surgical off-loading technique, the MHR in the treatment of chronic plantar neuropathic wounds. Many biochemical factors are implicated in the complex process of wound healing. In the case of diabetic neuropathic ulcers of the forefoot, additional mechanical factors induced by the presence of diabetic neuropathy lead to high pressure loads of the metatarsal heads on the plantar skin. With time, such chronic loads could favor ulcer formation. Removal of the causal mechanical factor could alleviate the pressure and allow wound healing. Neuropathic plantar ulcers are difficult-to-heal wounds and chronicity is associated to frequent hospitalizations, higher rates of amputation, and mortality. Early removal of the indirect causal agent, the resection of the metatarsal head, after failure of a well-conducted conservative standard of care could be a needed solution for wound healing and consequently a potential for reducing complications and costs.
Topics: Adult; Aged; Databases, Factual; Diabetic Foot; Female; Follow-Up Studies; Humans; Male; Metatarsal Bones; Middle Aged; Orthopedic Procedures; Recurrence; Treatment Outcome; Wound Healing
PubMed: 32870773
DOI: 10.1089/wound.2020.1261