Journal of Foot and Ankle Surgery (Asia Pacific)

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2023 | October-December | Volume 10 | Issue 4

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Jitendra Mangwani

Challenges and Recent Trends in the Management of Forefoot Disorders

[Year:2023] [Month:October-December] [Volume:10] [Number:4] [Pages:1] [Pages No:161 - 161]

   DOI: 10.5005/jp-journals-10040-1327  |  Open Access |  How to cite  | 



Vidhi Adukia, Ashish Mishra, Martin Hughes, Linzy Houchen-Wolloff, Maitravaarun Burgula, Jitendra Mangwani

Do Baseline Scores or Comorbidities Affect Patient-reported Outcome Measures Following First Metatarsophalangeal Joint Arthrodesis?

[Year:2023] [Month:October-December] [Volume:10] [Number:4] [Pages:4] [Pages No:162 - 165]

Keywords: Arthrodesis, Euro quality of life 5 dimension, First metatarsophalangeal joint, Manchester Oxford foot questionnaire, Osteoarthritis, Patient-reported outcome measures, Rheumatoid arthritis, Surgery

   DOI: 10.5005/jp-journals-10040-1314  |  Open Access |  How to cite  | 


Background: Arthrodesis is the gold standard treatment for patients with end-stage arthritis of the first metatarsophalangeal joint (MTPJ). The Manchester Oxford foot questionnaire (MOxFQ) and Euro quality of life (Qol) 5 dimension (EQ-5D) are patient-reported outcome measures (PROMs) commonly used following MTPJ arthrodesis. However, the impact of baseline scores and patient comorbidities on these PROMs is not well studied. Aim: The aim of this study is to identify the change in PROMs measured by MOxFQ and EQ-5D following the first MTPJ arthrodesis and to determine if the baseline scores and/or presence of comorbidities affected the change observed. Methods: Data was collected prospectively from patients who had undergone the first MTPJ arthrodesis for end-stage arthritis. The dataset included common comorbidities, baseline PROMs and PROMs following surgery. Results: A total of 90 patients were identified, of which 52 had complete PROMs data. The mean age was 56.9 ± 17.8 years, and male to female ratio was 1:4. Comorbidities included diabetes (2%), hypertension (21%), rheumatoid arthritis (RA) (43%), and current smokers (10%). The majority of cases were unilateral (94%), and 37% of patients had ipsilateral additional foot procedures carried out concomitantly. A significant change was seen in all domains of the MOxFQ as well as in the MOxFQ and EQ-5D total (p < 0.01). Baseline scores of both PROMs significantly correlated with the change seen in the scores (r = 0.5 and 0.6, respectively, p < 0.001). The presence of RA was found to significantly reduce the change in the EQ-5D total (p < 0.05). Conclusion: Following the first MTPJ arthrodesis, statistically significant changes were observed in EQ-5D and MOxFQ total and all the MOxFQ subdomains. Baseline scores in both PROMs correlated well with the change in scores following surgery, suggesting that we may be able to identify a baseline score that could predict outcomes. The presence of RA dampened the change seen in the EQ-5D total, which should form part of preoperative (pre-op) discussions with patients.



Sherif F Ahmed Kamel, Togay Koç

Lesser Metatarsophalangeal Joints Instability: A Comprehensive Literature Review

[Year:2023] [Month:October-December] [Volume:10] [Number:4] [Pages:9] [Pages No:166 - 174]

Keywords: Crossover deformity, Flexor tendon transfer, Lesser metatarsophalangeal joint instability, Metatarsalgia, Plantar plate, Plantar plate injury, Plantar plate repair

   DOI: 10.5005/jp-journals-10040-1318  |  Open Access |  How to cite  | 


Aim and background: Lesser metatarsophalangeal instability can result in forefoot pain and deformity. This represents a relatively common problem. Despite this, there has been little information about the main causes and management of this condition in the literature. The aim of this article is to review the current literature about the management of this problem and to highlight the role of plantar plate pathologies in pathogenesis. We also propose a management algorithm. Materials and methods: A comprehensive literature search was performed, with no time limit through PubMed, Medline, and Embase. The article abstracts were reviewed, and those that were not involving lesser metatarsophalangeal joints (MTPJs), nor in English were excluded. Results: A total of 313 articles were found by the search. After the removal of duplicates and exclusion as per methodology, 186 articles remained. We describe the anatomy of the plantar plate, clinical presentation, investigations, classification, and treatment options. We discussed the various outcome measures of different studies on this topic up to date. Conclusion: Plantar plate tears play a pivotal role in lesser metatarsophalangeal instability. Conservative management is the mainstay of initial management. If this fails, then surgical treatment is indicated. Clinical significance: We provided an up-to-date comprehensive literature review of this relatively common condition that is not fully understood.



Isabella Drummond, Joon Ha, Amit Patel, Francesc Malagelada, Lee Parker, Luckshmana Jeyaseelan

Thou Shalt not Fuse: Implant Survival Outcomes and Complications Following Arthroplasty in Hallux Rigidus

[Year:2023] [Month:October-December] [Volume:10] [Number:4] [Pages:7] [Pages No:175 - 181]

Keywords: Arthroplasty, Complications, Hallux rigidus, Metatarsophalangeal arthritis, Outcomes, Survival

   DOI: 10.5005/jp-journals-10040-1316  |  Open Access |  How to cite  | 


Aims and background: Hallux rigidus (HR) is a condition characterized by pain and loss of range of motion of the metatarsophalangeal joint (MTPJ) of the great toe caused by degenerative arthritis. The aim of this article is to present the clinical outcomes, survival, and complication profile of the available implants for the salvage of the first MTPJ. Materials and methods: This study is a narrative review of the current evidence base assessing joint-sparing procedures using interposition implants. A comprehensive literature search was performed in PubMed by two investigators, and data were categorized based on implant option. Results: Silastic, metallic, and polyvinyl alcohol (PVA) implants were analyzed. The majority of the studies demonstrated satisfactory clinical outcomes and survivorship, and low complication rates for all types of implants. Nevertheless, there are a few reports of poor results after arthroplasty for HR. Conclusion: Arthroplasty of the first MTPJ for the management of HR yields satisfactory functional outcomes and reasonable pain relief. Future prospective studies are needed to confirm the findings of the present study. Clinical significance: Arthroplasty may be a safe alternative to an arthrodesis while preserving the range of movement of the first MTPJ.



Tom Ankers, Anjani Singh, Christopher R Walker, Lyndon W Mason, Siva Sirikonda

Arthrodesis of the Second and Third Tarsometatarsal Joints: Comparison of Radiological and Clinical Results Using Combined or Individual Plating Techniques

[Year:2023] [Month:October-December] [Volume:10] [Number:4] [Pages:6] [Pages No:182 - 187]

Keywords: Arthritis, Fusion, Outcome studies, Plating, Tarsometatarsal joint

   DOI: 10.5005/jp-journals-10040-1311  |  Open Access |  How to cite  | 


Background: Arthrodesis is an effective treatment of midfoot arthritis in reducing pain and improving function. However, there is a known risk of nonunion. Our aim was to compare the outcomes of individual plating vs combined plating for the fusion of both the second and third tarsometatarsal joints (TMTJs). Our primary outcome was bone healing, and secondary outcomes include patient-reported outcome measures. Methods: All cases underwent primary arthrodesis of the second and third TMTJs. Arthrodesis was performed using either a single “H-shaped” plate (combined plating group) or using two separate plates (individual plating group). The outcome measures were bony union and the Manchester Oxford Foot Questionnaire score (MOX-FQ). Results: A total of 45 procedures were undertaken with a mean follow-up of 527 days. The combined plating group had 28 cases, and the individual plating group had 17 cases. There were 10 cases (35.71%) of nonunion in the combined plating group and two cases (11.76%) in the individual plating group. Multivariate regression analysis showed a significant relationship of union with the use of the individual plating group [p = 0.047, odds ratio (OR) 5.822]. Patients who had also undergone the first TMTJ fusion had an increased chance of union (p = 0.043, OR 9.896). No other factors showed significance. MOX-FQ scores were superior in the individual group at 6 months postsurgery, although this statistical significance was lost when the nonunions were excluded. Conclusion: This study is the first to report a difference in the union between combined plating and individual plating techniques in arthrodesis of the second and third TMTJs. We believe that individual plates permit a more anatomical reduction and greater compression at the site of arthrodesis as compared to a dual plate technique, achieving better union results and an early better functional outcome.



Kimberly Lam, Anjani Singh, Siva Sirikonda, Yajur Narang, Jehan Ghany, Lyndon W Mason, Vasileios Lampridis

Cryoablation of Morton's Neuroma: An Early Clinical and Radiological Outcome Study

[Year:2023] [Month:October-December] [Volume:10] [Number:4] [Pages:5] [Pages No:188 - 192]

Keywords: Cryoablation, Forefoot, Morton neuroma

   DOI: 10.5005/jp-journals-10040-1319  |  Open Access |  How to cite  | 


Introduction: Morton's neuroma (MN) is a common compressive neuropathy of the interdigital nerves. Nonoperative management is recommended initially, and many modalities have been described. Cryoablation (CA) has shown promising results; however, there are limited published studies in the literature. The purpose of this study was to assess the safety and efficacy of ultrasonography (US)-guided CA in patients with MN. Methods: A retrospective analysis was completed for 20 patients (24 MN) between June 2021 and September 2022. All patients had refractory MN symptoms from previous US-guided steroid and local anesthesia injections. CA was performed under continuous US monitoring as a single outpatient procedure with one cycle for 2 minutes. Telephone follow-up with a 0–10 numerical rating scale was performed at 6 weeks and 3 months post-CA. Results: The mean size of MN treated was 12.3 mm. Technical success was 100%. The mean preprocedure pain score was 8, which reduced to 0 at 6 weeks and 3 months follow-up in the treated MN. There were two cases of fibrosis in the webspace (12.5%) seen on magnetic resonance imaging (MRI), and 1 residual neuroma was observed (6%). There were no complications observed. Conclusion: In this series, US-guided CA performed by musculoskeletal radiologists was deemed a safe and effective treatment for MN. Clinical advantages of the procedure are good patient tolerance, single outpatient procedure, high patient satisfaction and reduced risk of scarring or residual neuroma. Further controlled prospective studies would be beneficial.



Hadley A Leatherman, Vasundhara Mathur, Siddhartha Sharma, Soheil Ashkani-Esfahani

Patient-reported Outcomes in Foot and Ankle Practice: Where do We Stand in 2022?

[Year:2023] [Month:October-December] [Volume:10] [Number:4] [Pages:3] [Pages No:193 - 195]

Keywords: Activities of daily living, American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale, Foot ankle ability measure score, Orthopedics, Patient-reported outcome, Shared decision-making, Society scale, Surgery, Survey, Parameters of American Orthopaedic Foot and Ankle Society

   DOI: 10.5005/jp-journals-10040-1284  |  Open Access |  How to cite  | 


Patient-reported outcome measures (PROMs) enable healthcare professionals to monitor their patient's physical, mental, and social health status. In this commentary, we provide an overview and a table summarizing the PROMs currently being implemented in foot and ankle surgery, along with their individual advantages and disadvantages. We also discuss barriers to meaningful implementation and the proven strategies to overcome those barriers. Even though research has demonstrated the positive role that PROMs can play in patient care, currently, only one-third of orthopedic clinics use PROMs at all. Further, <10% of orthopedic surgeons themselves utilize them in their everyday practice. We believe that for many providers, the reason behind their lack of acceptance of PROMs is because of a gap in knowledge about the many benefits of doing so. For some, PROMs may also be perceived as an additional requirement to insurance and hospital protocols, thus creating another barrier to implementation. In order to overcome these impediments, we suggest that the role of PROMs be thoroughly researched and the merits of incorporating its use into everyday clinical practice be communicated to researchers, physicians, and policymakers across the discipline. In addition, it is essential that the opinions of surgeons and patients be taken into consideration and healthy dialogue is undertaken before PROMs are introduced on a large scale. In summary, we hope our manuscript gives orthopedic surgeons, researchers, and administrators interested in PROMs a comprehensive look at where we currently are with PROMs and the directions that future research can take.



Vincent P Stahel, Niaz Ahankoob

Percutaneous Bone Adhesives: A Hypothetical Adjunct to Improve Healing Rates in Critical Foot and Ankle Injuries

[Year:2023] [Month:October-December] [Volume:10] [Number:4] [Pages:2] [Pages No:196 - 197]

Keywords: Bone adhesives, Delayed union, Jones fracture, Nonunion

   DOI: 10.5005/jp-journals-10040-1291  |  Open Access |  How to cite  | 



Rajagopalakrishnan Ramakanth, Rajesh Simon, Sundararajan Silvampatti Ramasamy, Abhishek Kini, Pratheeban Karthikeyan, Terence Dsouza, Shanmuganathan Rajasekaran, Madhu Periasamy

Midfoot Charcot and Need for Arch Reconstruction and Superconstruct—“Lessons Learnt”: Multicentric Indian Experience

[Year:2023] [Month:October-December] [Volume:10] [Number:4] [Pages:10] [Pages No:198 - 207]

Keywords: Beam screws, Charcot's arthropathy, Diabetic mellitus, Lateral column fusion, Medial column fusion, Midfoot, Superconstruct

   DOI: 10.5005/jp-journals-10040-1324  |  Open Access |  How to cite  | 


Aims and background: Charcot's neuroarthropathy (CN) affecting the midfoot leads to fractures and dislocation of the tarsal bones and displaced predominantly to the plantar aspect of the foot. Further, loading on these bony prominences leads to midfoot ulcers. Hence, corrective fusion of the involved medial and/or lateral columns is necessary to protect the foot from ulcers and recurrent infections. Our primary objective was to assess the radiological and functional outcomes of midfoot fusion in CN. A secondary aim was to estimate the incidence of complications such as loss of fixation, implant fracture, and wound dehiscence following the procedure. Materials and methods: This is a retrospective study of all patients operated in three different centers by four different surgeons, between 2018 and 2022. All patients who were diagnosed with Charcot's arthropathy of the midfoot were included in the study. Patients with hindfoot Charcot's arthropathy, arthritis due to posttraumatic, inflammatory, and infective sequelae were excluded. Data (radiological and functional) of all patients in the three orthopedic centers were collected. Functional outcomes were assessed using the midfoot—American Orthopaedic Foot and Ankle Society (AOFAS) and Foot and Ankle Outcome Score (FAOS) scoring system preoperatively and at the final follow-up. Radiological assessment was done for union and the lateral talometatarsal (TMT) (Meary's) angle, talo-first metatarsal angle in antero-posterior (AP) view, calcaneal pitch, and cuboid height were utilized for assessing the foot reconstruction in sagittal and axial planes. Results: We had a total of 98 patients (center-1—55), (center-2—15), and (center-3—28) with a mean follow-up ranging from 10 ± 2 to 79 ± 12 months. There was significant improvement in midfoot AOFAS scores and FAOS postoperatively across the centers; however, it was statistically significant in center-1 (p-value = 0.0005) and center-2 (p-value = 0.042). Stable union (bony/fibrous) ranged between 78.5 and 95%. Meary's angle improved in all centers, and it was statistically significant in center-1 (p-value = 0.0005), talar-1st MT angle in AP view, and cuboid height improved significantly in center-1 and 2 (p-value = 0.0005) while calcaneal pitch showed statistically significant improvement center-1 (p-value = 0.042), and center-3 (p-value = 0.0005). The total complication rate ranged between 46% and 51% [minor (6–23%), major (25–40%)] with screw breakage at the TMT junction being the most common complication encountered. The reoperation rate ranged from 0 to 27% across the centers. Only one patient needed amputation due to recurrent infection. Conclusion: Based on the observations in this study, we would recommend early surgical intervention in midfoot CN. Medial and lateral column fusion with intramedullary beam screws with or without superconstruct results in an acceptable bony union/fibrous union that provides a plantigrade stable foot despite complications like implant breakage, loss of fixation, and wound infections.


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