MÜLLER WEISS DISEASE: RADIOLOGICAL EVALUATION AND PROPOSED TREATMENT ALGORITHM
| Autor: | McKenna, Raymond, Wong-Chung, John, Tucker, Adam, Gibson, Desmond, Heyes, Gavin, Walls, Andrew, Prout, Honor, Wilson, Alistair, McQuail, P., Stanley, C., Kearns, S., Matthews, S., McAuley, D., Wilson, A., O’ Reilly, M, Mohamed, KMS, McKenna, J, Bayer, T |
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| Jazyk: | angličtina |
| Rok vydání: | 2019 |
| Předmět: | |
| Zdroj: | The Ulster Medical Journal |
| ISSN: | 2046-4207 0041-6193 |
| Popis: | Introduction Müller Weiss disease is becoming increasingly recognized and is of unknown etiology. Maceria et al. formulated a classification based upon the Méary-Tomeno talo-first metatarsal angle and coined the term ‘paradoxical pes planus varus’ proposing hallmark deformities. Acknowledging there is no gold standard for treatment, various surgical modalities have been advocated in the literature e.g. isolated lateral displacement calcaneal osteotomy as sole treatment. The question subsequently arises; which joints to fuse in Muller-Weiss disease? Although no consciences prevails, one must postulate fusion should include those affected. For the purpose of establishing an algorithm in the surgical treatment of Muller-Weiss disease, we therefore set out to study its clinical and radiographic features, including pathoanatomy and metabolism as determined by SPECT-CT. Methods We studied 63 consecutive feet presenting with Muller-Weiss disease (15 to 86 years, 18 men, 26 women). History and examination by consultant in all cases. Plain radiographs included standing anteroposterior both ankles, hindfoot alignment views, lateral standing of both ankles and feet, medial oblique both feet and dorsoplantar standing and SPECT-CT. Surgery performed on significantly symptomatic feet unresponsive to minimum of six months conservative measures. Méary’s talo-first metatarsal angles measured. On dorsoplantar radiographs the anteroposterior thickness of the navicular was measured at each naviculo-cuneiform joint perpendicular to transverse axis of the medial pole of the navicular. The percentage compression was calculated at each joint and the degree of extrusion of the medial pole. Hindfoot alignment measured using method of Saltzmann. Study approved by our local research and ethics department and in accordance with General Data Protection Regulation guidelines. Statistical analysis was performed using SPSS software. Results Using R2 coefficient of determination we found no correlation at any level between extrusion and the degree of compression. With respect to hindfoot alignment and Méarys angle there was no significant correlation (R2=0.003) Shapiro-Wilk test demonstrates a normal distribution of extrusion in both unilateral and bilateral cases. In 95.2% of unilateral cases extrusion significantly greater on affected side (P Introduction Degenerative changes at the tibiotalar joint affect 1% of adults. The optimal management is complex, arthrodesis traditionally is the reference standard. New generation total ankle replacements(TARs) in appropriately selected patients, have reported 10 year survival rates up to 89% from design centres, with good reported outcomes. We report multicentre, intermediate to long-term outcomes, of the Hintegra TAR. Methods This study utilised a prospective, nonrandomised observational approach to assess survival and revision rates, in all Hintegra TARs, performed in Musgrave Park and Altnagelvin Hospitals from 2004-2013. All procedures performed, by two fellowship trained foot and ankle consultants. Review clinics were established in 2018 to update patient history, clinical examination, radiographs, AOFAS hindfoot scores and Charlson Comorbidity Index(CCI). Radiographs were reviewed for evidence of loosening, by two authors who were blinded to clinical outcomes. Results Between 30/03/2004-18/01/2013 62 primary TARs were performed on 58 patients. Excluding the deceased (n=9) and those lost to follow up (n=1) our mean follow up was 12 years 3 months, average AOFAS score 78. During the first 4 years 11/23(48%) required additional surgery; reduced following a modification of the surgical technique. Our 5 and 10 year survival rates are 84% (52/62) and 71% (27/38) respectively. Risk factors for revision include BMI>30 (Chi-squared P=0.006), smoking history (Chi-Squared P=0.027) and lower ASA scores (One-way ANOVA P=0.034). No association between CCI and revision. Asymptomatic osteophyte formation and polyethylene wear noted after 8-10 years. 6.4% deep infection rate. Conclusion The Hintegra TAR is a good alternative in the management of ankle arthritis, providing good function and sustained pain relief in the intermediate to long term Implications We would stress the steep learning curve and the importance of achieving correct alignment to maximise longevity. Caution is advised in patients who are obese, smokers/ex and those with a high functional demand. Introduction Pes planus is a common condition affecting approximately 12-14% of the population. Patients with pes planus commonly present with medial sided ankle and forefoot pain during weight bearing. Lateral ankle pain is generally seen in patients with more advanced disease. Osteochondral lesions (OCL’s) of the head of the talus at the talonavicular joint are well described in this condition. However, despite the frequency of ankle pain as a presentation in this condition, no studies have yet sought to identify the prevalence of tibiotalar OCL’s. Methods All Magnetic Resonance Imaging (MRI) studies requested for pes planus by a single Consultant Foot and Ankle Surgeon in a single institution over the past five years were reviewed to determine the co-existence of a tibiotalar osteochondral lesion (OCL). A subsequent chart review was performed on all patients with co-existent OCL’s to determine the aetiology of pes planus and to determine other relevant past medical history such as ankle trauma. Exclusion criteria were patients with incomplete imaging or those who had recent ankle surgery in whom the altered signal on MRI obscured accurate interpretation of the tibiotalar chondral surface. Results 54 patients were referred for an MRI of their foot and ankle, 11 of whom had an MRI of both feet. Of the 65 scans, 5 were excluded. Four MRI’s had only included the foot and one patient had recent ankle surgery. 23 of the 59 patients who had an MRI of their foot and ankle for pes planus had an OCL, yielding a prevalence of 39.2% in this cohort. The majority of osteochondral defects occurred on the medial talar dome with 14 of the 23 patients having medial talar dome OCL’s, 9 had lateral talar dome OCL’s and 5 had distal tibia OCL’s. Conclusion Tibiotalar ostechondral lesions may partially account for the pain experienced by a substantial proportion of patients with pes planus deformity. The prevalence of this finding may also infer utility of Single-photon emission computed tomography (SPECT) scanning patients with pes planus who have ankle pain, to better delineate the patient’s pain source prior to intervening surgically. Surgeons should consider outruling tibiotalar OCL’s in patients with pes planus complaining of ankle pain as it may need consideration when planning treatment. Introduction Weight-bearing radiographs are a critical modality in assessing various foot and ankle conditions. Several studies indicate the benefits of weight-bearing radiographs, to provide the most precise assessment of foot and ankle bony anatomy. We aimed to establish the proportion of bodyweight placed through the limb, when a weight-bearing radiograph was requested, with the presumption that greater than 75% satisfied a weight-bearing status Methods Twenty seven patients included with forty two radiographs taken (n=42). Data collection was over a one month period (Feb 2019), in a regional trauma centre. Non-weight-bearing views were excluded. Full body weight was recorded with subsequent measurements recorded at the time the weight-bearing radiograph. All measurements were obtained using the same set of scales. Percentage weight through the foot was calculated and compared to our 75% body weight standard. Results Mean percentage body weight was 79.7% ± 6.7%, with the median being 90.8%. 64% of radiographs were > 75% presumed body weight; with 52% being > 90% weight. Full weight-bearing of 100% occurring in 6/42 radiographs. Conclusions There are large degrees of variability in the weight applied to the injured limb during a weight-bearing radiograph. 64% of radiographs are over our standard of 75% body weight applied. Interpreting clinicians must be mindful to not assume satisfactory weight-bearing in all cases. A multitude of factors may influence this, including patient education, non-compliance, pain limitations, confounding patient factors (mobility, stability, visual impairment etc). This study raises points surrounding the evaluation of weight-bearing radiographs, including their accuracy, reliability and assumptions of interpreting clinicians. Introduction There has been much debate regarding the aetiology and pathogenesis of hallux valgus and it appears to be multifactorial with contracture or tightness of the Achilles tendon and more specifically the gastrocnemius being implicated as an intrinsic factor. The purpose of this study was to look at the association between hallux valgus, gastrocnemius tightness and genu valgum. Methods Patients were divided into a case and control group, n=25 in each group. The case group observed adult patients who were referred primarily because of symptomatic hallux valgus and were assessed for the following: hallux valgus stage; presence or absence of isolated gastrocnemius tightness; presence or absence of genu valgum. The control group excluded those with pre-existing hallux valgus, genu valgum and rheumatoid arthritis and were assessed for isolated gastrocnemius tightness. Results There was a statistically significant association between the presence of genu valgum and hallux valgus when comparing both groups with a p value |
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