Thesis (doctoral)--Lund University, 1995. / Added t.p. with thesis statement and abstract inserted.

A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, in partial fulfilment of the requirements for the degree of Master of Medicine in the branch of Orthopaedic Surgery / Introduction: The hallux valgus interphalangeus deformity is described as rare, but improved outcomes in hallux valgus surgery is associated with its surgical correction via an Akin osteotomy. The hypothesis of this study is that hallux valgus interphalangeus makes a contribution to the total valgus deformity of the hallux. Methods: A radiographic analysis of 285 foot x-rays utilising a standardised radiographic and measurement technique was performed. Results: The average contribution of the interphalangeal angle (IPA) to the total valgus deformity of the hallux (TVDH) across the whole study population was a mean (SD) of 37.9% (21.2). The average contribution of IPA to TVDH was greater in feet without hallux valgus (58.0%) when compared to feet with hallux valgus (28.3%). Hallux valgus interphalangeus is common, particularly in Caucasians (p=0.01) and makes a significant contribution to the total valgus deformity of the hallux (p <0.01). The contribution to total valgus deformity of the hallux is more significant in mild hallux valgus. There is an inverse relationship between the interphalangeal angle and other angular measurements in the foot. Conclusion: Hallux valgus interphalangeus is a common entity and its significant contribution to the total valgus deformity of the hallux dictates that hallux valgus interphalangeus must be incorporated in management algorithms. The total valgus deformity of the hallux should replace the isolated concepts of hallux valgus and hallux valgus interphalangeus.

Objectives: This work solves the problem of hallux valgus deformities, aetiology, biomechanics, the possibility of conservative therapy, surgery and post-operative treatment. Methods: Data collection was made by questionnare survey of people during thein hospitalization for hallux valgus surgery and than after 4-5 months. Questionnaires are targeted primarily to conservative therapy and post-operative rehabilitation therapy. Results: Due to the small number of probands (20 people) can not be drawn significant conclusions. Hallux valgus deformity is often solved by surgery rather than by conservative treatement, mostly because of the decision of patients for treatment, when the deformity is in an advanced stage. Postoperative rehabilitation treatment has a positive effect on recovery, particularly in terms of reducing pain and swelling, to facilitate walking (subjectively).

Hallux Abducto Valgus (HAV) is a common cause of foot pain causing deformity and often disability. The female population is more frequently affected by HAV than the male population with the two main causative factors being congenital and inappropriate footwear. Surgery is the most prevalent treatment, but it does not take into consideration the biomechanical effects on the biomechanical chain and therefore the deformity frequently reoccurs and complications after surgery are many. The aim of this study is to compare the efficacy of the Brantingham protocol versus the HAV Night Splint in the treatment of painful HAV. Thirty participants were selected to participate in the study and certain criteria had to be met. Participants were randomly divided into two groups, Group 1 was treated using a chiropractic protocol. The Brantingham Protocol that consisted of mobilization and specific adjustment of the first metatarsophalangeal joint was used. Group 2 was treated by the use of a HAV Night Splint. Patients were treated over a 2-week period, twice a week with a 1-week follow up and a 1-month follow up. The lasting effect of the individual treatments was determined by the follow-up periods. Objective and subjective measurements were taken at each visit. Subjective measurements consisted of the McGill pain questionnaire (Melzack, 1975) (Appendix D), visual analogue scale (Masarsky and Todres-Masarsky, 2001) (Appendix B) and the foot function index pain scale (Saag et al., 1996) (Appendix C). Objective measurements consisted of passive Plantar and Dorsiflexion of the First metatarsophalangeal joint. The results indicated a statistical and numerical significance within and between each group both subjectively and objectively. Group 1 proved to be superior to Group 2 in the treatment of painful HAV. In conclusion, both the Brantingham Protocol and the HAV Night Splint proved to be effective in the treatment of painful HAV. However, Group 1 proved to be superior to Group 2 in the treatment of painful HAV. / Dr. Birdsey Mr. Zipfel

Hallux valgus and hallux limitus are two common foot pathologies that may require surgical intervention. While the modified Austin bunionectomy and the Youngswick osteotomy/cheilectomy respectively, are often used to correct these conditions, insufficient research has been published regarding the effects of these procedures on plantar pressure distribution of the foot. This thesis involves a series of six studies investigating topics relating to radiographic measurements and plantar pressure distribution over a two-year period, in normal feet and in hallux valgus and hallux limitus feet before and after corrective surgery.A review of the literature is presented relating to the development of plantar pressure measurement technology, the aetiology and surgical management of hallux valgus and hallux limitus, the reliability of the EMED system used in the studies, and the related clinical uses of plantar pressure measurement.An initial study was designed to investigate the reliability measurements using a simplified two-step method of data collection as compared to the traditional mid-gait technique of ten normal asymptomatic subjects. Intra-class correlation coefficients were calculated and compared for the pressure variables of contact area, contact time, maximum force and peak pressure of ten regions of the foot.A study to determine normal reference range values for the EMED-SF system was then conducted using thirty healthy subjects and the two-step method of data collection. Descriptive statistical reporting of peak pressure, mean pressure and pressure-time- integrals were presented for ten regions of the foot.Three related studies on radiographic and plantar pressure measurement differences, and their relationships were made using thirty normal, hallux valgus and hallux limitus feet. Various angular and linear radiographic measurements were tested for intra-rater ++ / reliability of measurement and pressure variables of peak pressure, mean pressure and pressure-time-integral of 10 regions of the foot were recorded and one way analysis of variance employed to assess any significant differences.Finally, two independent two-year prospective studies were designed to investigate the effects of the modified Austin bunionectomy for hallux valgus and the Youngswick osteotomy/cheilectomy for hallux limitus on plantar pressure distribution of the forefoot. In addition, fundamental radiographic measurement changes of the forefoot of hallux valgus subjects and range of motion changes of the first metatarsophalangeal joint of hallux limitus subjects were conducted. Thirty-six healthy volunteers acted as control subjects, 31 subjects (44 feet) with hallux valgus and 17 subjects (23 feet) with hallux limitus were included in the study. Using an EMED-SF system, plantar pressure variables of peak pressure, pressure-time-integral, contact time, maximum force and force-time-integral were recorded at six regions of the forefoot, pre-operation and repeated at three, six, 12, 18 and 24-months post-operation for surgical subjects. Control subjects were tested at zero and 24-months. Descriptive statistics, multivariate and univariate analysis of variance with contrasts, t-tests of significance and correlations between certain measurement parameters were used in the analysis of the results.The findings of these studies suggest that the two-step method of data collection of plantar pressure measurements is more reliable that the traditional mid-gait technique for most pressure variables. Consequently, the two-step method was employed as the preferred method of data collection in this series of studies.With respect to radiographic differences between normal, hallux valgus and hallux limitus, it appears that hallux valgus feet have significant increases in ++ / metatarsus primus varus and first metatarsal protrusion distance, while hallux limitus feet have increased hallux abductus interphalangeal angles. Comparison of pressure variables between each group demonstrate hallux valgus feet have a medial localisation of peak pressure beneath the first, second and third metatarsal heads, suggesting that hyperpronation of the foot is associated with the development of hallux valgus. Hallux limitus feet on the other hand, show increased pressure beneath the hallux, third and fourth metatarsals and lesser toes, indicating a more lateral locus of pressure loading, suggestive -of the foot functioning in a more supinated position. No significant relationship was found between any radiographic parameter and pressure variable tested in either group of subjects.Plantar pressure measurement changes show the greatest variation during the initial three to six months following surgical treatment of hallux valgus and hallux limitus. The Youngswick osteotomy/cheilectomy for the treatment of hallux limitus produces near-normal range of motion of the first metatarsophalangeal joint. Pressures of the first metatarsal head remain relatively constant over the period of measurement, while a significant reduction of the hallux and lateral metatarsals were noted, related to increased dorsiflexion of the hallux. Pressures of the second metatarsal head remained significantly above pre-operation levels. The modified Austin bunionectomy for the treatment of hallux valgus produced 24-month radiographic changes consistent with accepted values. Pressure variables of the hallux reduced to normal values, with the first metatarsal head demonstrating an initial significant decrease and subsequent increase by twelve months post-operation to remain with the second metatarsal head at relatively similar values to pre-operation measurements.The research demonstrates ++ / the two-step method of data collection is a viable means of obtaining reliable plantar pressure measurement data in the clinical situation. The investigations into radiographic and plantar pressure distribution indicate that structural radiographic and functional differences exist between normal, hallux valgus and hallux limitus feet. However, no relationship could be found between any of the radiographic parameters and pressure variables tested.The modified Austin bunionectomy for hallux valgus significantly reduced fundamental radiographic measurements to accepted post-operative values, while the Youngswick procedure for hallux limitus significantly increased the amount of post-operative dorsiflexion of the hallux to normal values. The research demonstrates that immediate and longer-term functional changes to the forefoot occur following the surgical treatment of hallux valgus and hallux limitus, however plantar pressure measurements do not return to normal values. No correlation was found between plantar pressure measurements and post- operative radiographic measurements in the hallux valgus group. However, the increased amount of dorsiflexion of the hallux post-operatively in the hallux limitus group was correlated with reduced lateral loading of the forefoot. Post-operation changes of plantar pressure distribution indicate that the rehabilitative period required to achieve stable foot function is between twelve to eighteen months. Furthermore, plantar pressure measurement technology offers the clinician a useful tool to monitor foot function prior to and following therapeutic intervention.

INTRODUÇÃO: O hallux valgus é a deformidade mais comum do pé do adulto e é frequentemente incapacitante requerendo tratamento cirúrgico. O ângulo articular metatarsal distal (AAMD) é uma das variáveis importantes no estudo da deformidade, mas possui baixa correlação interobservadores quando avaliado pela radiografia. O objetivo deste estudo foi avaliar um método tomográfico de aferir este ângulo comparando-o com a medida radiográfica existente. MATERIAL E MÉTODOS: O AAMD de 77 pés (43 pacientes) foi avaliado através de tomografia computadorizada por dois observadores. Os valores encontrados foram comparados entre os observadores e entre a medição radiográfica utilizando o coeficiente de correlação e concordância (CCC) proposto por King e análise de Bland-Altmann para concordância entre os métodos. RESULTADOS: Foi encontrado índice de concordância alto na medição tomográfica entre os observadores com CCC = 0,90 e p < 0,001. Em relação a mensuração radiográfica com a tomográfica houve uma concordância com CCC = 0,667 de com p < 0,001. Na análise gráfica de Bland-Altman a presença de round sign positivo sugere um aumento da diferença da medição radiográfica com a tomográfica e está associado a valor alto do AAMD. CONCLUSÃO: A mensuração do AAMD pelo método tomográfico demonstrou maior correlação interobservadores do que o método radiográfico. Em casos em que há dúvida sobre alteração patológica da inclinação da cabeça metatarsal com ângulos articulares metatarsais distais (AAMD) elevados e, principalmente, com a presença de round sign positivo, a tomografia pode ser um método alternativo para planejamento cirúrgico pré-operatório.

INTRODUÇÃO: O hallux valgus é a deformidade mais comum do pé do adulto e é frequentemente incapacitante requerendo tratamento cirúrgico. O ângulo articular metatarsal distal (AAMD) é uma das variáveis importantes no estudo da deformidade, mas possui baixa correlação interobservadores quando avaliado pela radiografia. O objetivo deste estudo foi avaliar um método tomográfico de aferir este ângulo comparando-o com a medida radiográfica existente. MATERIAL E MÉTODOS: O AAMD de 77 pés (43 pacientes) foi avaliado através de tomografia computadorizada por dois observadores. Os valores encontrados foram comparados entre os observadores e entre a medição radiográfica utilizando o coeficiente de correlação e concordância (CCC) proposto por King e análise de Bland-Altmann para concordância entre os métodos. RESULTADOS: Foi encontrado índice de concordância alto na medição tomográfica entre os observadores com CCC = 0,90 e p < 0,001. Em relação a mensuração radiográfica com a tomográfica houve uma concordância com CCC = 0,667 de com p < 0,001. Na análise gráfica de Bland-Altman a presença de round sign positivo sugere um aumento da diferença da medição radiográfica com a tomográfica e está associado a valor alto do AAMD. CONCLUSÃO: A mensuração do AAMD pelo método tomográfico demonstrou maior correlação interobservadores do que o método radiográfico. Em casos em que há dúvida sobre alteração patológica da inclinação da cabeça metatarsal com ângulos articulares metatarsais distais (AAMD) elevados e, principalmente, com a presença de round sign positivo, a tomografia pode ser um método alternativo para planejamento cirúrgico pré-operatório.

INTRODUÇÃO: O hallux valgus é a deformidade mais comum do pé do adulto e é frequentemente incapacitante requerendo tratamento cirúrgico. O ângulo articular metatarsal distal (AAMD) é uma das variáveis importantes no estudo da deformidade, mas possui baixa correlação interobservadores quando avaliado pela radiografia. O objetivo deste estudo foi avaliar um método tomográfico de aferir este ângulo comparando-o com a medida radiográfica existente. MATERIAL E MÉTODOS: O AAMD de 77 pés (43 pacientes) foi avaliado através de tomografia computadorizada por dois observadores. Os valores encontrados foram comparados entre os observadores e entre a medição radiográfica utilizando o coeficiente de correlação e concordância (CCC) proposto por King e análise de Bland-Altmann para concordância entre os métodos. RESULTADOS: Foi encontrado índice de concordância alto na medição tomográfica entre os observadores com CCC = 0,90 e p < 0,001. Em relação a mensuração radiográfica com a tomográfica houve uma concordância com CCC = 0,667 de com p < 0,001. Na análise gráfica de Bland-Altman a presença de round sign positivo sugere um aumento da diferença da medição radiográfica com a tomográfica e está associado a valor alto do AAMD. CONCLUSÃO: A mensuração do AAMD pelo método tomográfico demonstrou maior correlação interobservadores do que o método radiográfico. Em casos em que há dúvida sobre alteração patológica da inclinação da cabeça metatarsal com ângulos articulares metatarsais distais (AAMD) elevados e, principalmente, com a presença de round sign positivo, a tomografia pode ser um método alternativo para planejamento cirúrgico pré-operatório.

A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, in partial fulfilment of the requirements for the degree of Master of Medicine, Johannesburg, 2018 / Introduction: The hallux valgus interphalangeus (HVI) deformity has a common association with hallux valgus and hallux rigidus. The radiographic measurement of the hallux valgus interphalangeus is formed by the angle between the long axes of the proximal and distal phalanges. The normal value for this angular deformity in the coronal plane is less than 10 degrees. The reliability of measuring the hallux interphalangeal angle has not been verified as yet .The purpose of this study is to analyse the intra- and inter-observer reliability of measurements of the interphalangeal angle by orthopaedic surgeons. This study is going to be the first study to evaluate the reliability and reproducibility of the hallux valgus interphalangeal angle. Methods: Twenty one X-ray prints (images) of the weight bearing foot constituted a set. Three such sets were sent to each evaluator at four week intervals. Sixteen qualified orthopaedic surgeons were asked to measure the hallux interphalangeal angle of all twenty one X-ray images at three different occasions. After all three sets were measured, data was retrieved and statistically analysed to determine the incidence of inter- and intra-observer variability and reliability in the measurement of the hallux interphalangeal angle. Results: Reproducibility of the hallux interphalangeal angle measurement was assessed using three categories which included the ability to measure the same angle three times and achieve: three degrees or less, five degrees or less, more than five degrees. The intra-observer reliability was found to be 5 degrees and less in 75.2% of participants and for the inter-observer reliability was 61.2%. The researcher did not find significant correlation between the surgeons’ level of experience with respect to the reliability of measurement of the hallux interphalangeal angle. Conclusion: The reliability and reproducibility of measurement of the hallux interphalangeal angle is low. The level of experience of the surgeon does not improve this reliability. / XL2018

INTRODUCCIÓN La limitación en el plano sagital del movimiento y el dolor de la primera articulación metatarsofalángica fue denominada por primera vez "hallux flexus" en 1887 por Davies-Colley. En 1888 Cotterill fue el primero en utilizar el término "hallux rigidus" para describir esta patología. Después del hallux valgus, el hallux rigidus es la patología que más frecuentemente afecta a la primera articulación metatarsofalángica, pudiendo ser más imposibilitante para el paciente.Después de más de 100 años desde esta descripción inicial todavía permanece abierto el debate en torno a la etiología de ésta patología. OBJETIVOSNuestro objetivo es concretar, con metodología científica, las variantes anatómicas que influyen en la etiopatogenia del hallux rigidus. MATERIAL Y MÉTODOSSe ha realizado un estudio retrospectivo de casos y controles.Los casos son una serie de pacientes afectos de hallux rigidus intervenidos en varios centros (Hospital Universitari de Tarragona Joan XXIII, Hospital Comarcal de Mora d'Ebre, Hospital de San Rafael y Hospital de Sant Pau i Santa Tecla). Se revisaron un total de 248 casos de hallux rigidus, de los cuales se seleccionaron 132, el resto fueron descartados por diferentes motivos. Se buscó un grupo control con pies clínica y radiológicamente normales. Ambos grupos eran comparables en cuanto al lado, el sexo y la edad.Se han estudiado las siguientes variables:A- Variables Clínicas y Morfológicas: se han recogido 9 variables en cada pie. B- Mediciones Radiológicas: se han realizado 14 mediciones en la proyección dorsoplantar en carga y 7 mediciones en la proyección de perfil en carga de cada pie. En la metodología estadística se ha realizado un análisis descriptivo, análisis univariable, análisis de la exactitud de las medidas y un análisis multivariable.RESULTADOSSe ha realizado un análisis estadístico comparativo de los resultados de las mediciones entre el grupo de casos de hallux rigidus y el grupo control. Asimismo se han descrito los resultados obtenidos en la diferenciación en función del sexo, de la edad, del grado de hallux rigidus, de la fórmula metatarsal y de la fórmula digital. Se han calculado los valores límite o de corte de los parámetros estudiados que han tenido significación estadística. Por último se ha realizado el análisis multivariable de las mismas.DISCUSIÓNSe realiza una comparación de nuestros resultados para cada variable con respecto a la bibliografía previa.CONCLUSIONES · La forma aplanada de la cabeza del primer metatarsiano está asociada con la presencia de hallux rigidus, siendo el punto de corte de mayor discriminación.· La mayor longitud del primer metatarsiano está asociada con la presencia del hallux rigidus.· En pies con hallux rigidus, el Ángulo Metatarsofalángico del Hallux es mayor de 14º. · Un Angulo Metatarsofalángico del Segundo Dedo mayor de -8º está relacionado con la presencia de hallux rigidus. · Una mayor distancia de los sesamoideos a la articulación metatarsofalángica del hallux está asociada con la presencia de hallux rigidus.· En nuestra serie no hay hipertrofia de la cortical medial del segundo metatarsiano en los casos de hallux rigidus.· No hemos encontrado relación estadísticamente significativa entre la Flexión Dorsal del Primer Metatarsiano y la presencia de hallux rigidus.· No hemos encontrado relación estadísticamente significativa entre la Flexión Plantar del Hallux y la presencia de hallux rigidus.· No hemos encontrado relación estadísticamente significativa entre las Alteraciones en el Retropié y la presencia de hallux rigidus.· No hemos encontrado relación estadísticamente significativa entre la existencia de un Pie Plano y la presencia de hallux rigidus. / INTRODUCTION Limitation of movement in the sagittal plane and pain in the first metatarsophalangeal joint was named "hallux flexus" for the first time in 1887 by Davies-Colley. In 1888 Cotterill was the first to use the term "hallux rigidus" to describe this condition. After hallux valgus, hallux rigidus is the disease that most commonly affects the first metatarsophalangeal joint, and can be more disabling for the patient.More than 100 years after this initial description, the debate on the etiology of this disease remains open. OBJECTIVESOur objective is to specify, by means of a scientific methodology, the anatomical variations that influence the pathogenesis of hallux rigidus. MATERIAL AND METHODSA retrospective study of cases and controls was performed.The cases were a series of patients afflicted with hallux rigidus operated on in several centres (Hospital Universitari de Tarragona Joan XXIII, Hospital Comarcal de Mora d'Ebre, Hospital de San Rafael and Hospital de Sant Pau i Santa Tecla). Out of a total 248 cases of hallux rigidus examined, 132 were chosen, the remainder being ruled out for various reasons. A control group with clinically and radiologically normal feet was established. Both groups were comparable in terms of side, sex and age.The following variables were studied:A- Clinical and Morphological Variables: 9 variables were collected from each foot. B- Radiological Measurements: 14 weight-bearing dorsoplantar projection measurements and 7 weight-bearing lateral projection measurements were taken of each foot. The statistical methodology included a descriptive analysis, univariable analysis, an analysis of measurement accuracy and a multivariable analysis.RESULTSA comparative statistical analysis of the resulting measurements between the group of patients with hallux rigidus and the control group was carried out. The results obtained from the differentiation according to sex, age, degree of hallux rigidus, metatarsal formula and digital formula were likewise described. Limit and cut off values were calculated for the parameters showing statistical significance. Finally a multivariable analysis of the latter was performed. DISCUSSIONA comparison of our results for each variable with those of previous bibliography is carried out.CONCLUSIONS · The flattened shape of the first metatarsal head is associated with the presence of hallux rigidus, constituting the most discriminating cut off point.· The increased length of the first metatarsal is associated with the presence of hallux rigidus.· The Metatarsophalangeal Angle is greater than 14º in feet suffering from hallux rigidus. · A Metatarsophalangeal Angle of the Second Toe greater than -8º is related to the presence of hallux rigidus. · A greater distance between the sesamoids and the metatarsophalangeal angle of the hallux is linked to the presence of hallux rigidus.· In our series, medial cortical hypertrophy of the second metatarsal was not observed in cases of hallux rigidus.· We have not found a statistically significant relationship between Dorsal Flexion of the First Metatarsal and the presence of hallux rigidus.· We have not found a statistically significant relationship between Plantar Flexion of the Hallux and the presence of hallux rigidus.· We have not found a statistically significant relationship between Rearfoot Disorders and the presence of hallux rigidus.· We have not found a statistically significant relationship between the occurrence of Flat Feet and the presence of hallux rigidus.