Hallux varus is a rare cause of pain in the foot mostly occurring after failed hallux valgus surgery. We reviewed 12 patients with unilateral hallux varus treated with soft tissue techniques (4x), arthrodesis of the first metatarso-phalangeal joint (3x) or with a distal chevron osteotomy (5x) with medial transposition of the first metatarsal head and reconstruction of the soft tissues on the lateral side of the metatarsophalangeal joint. 10 patients had previous hallux valgus surgery, in 2 cases the deformities were of unknown origin. 1 male and 11 female patients were followed up on average 26.4 months postoperatively. AOFAS hallux score improved from 46 (range 10–75) to 86 (range 72–95) points. The metatarsophalangeal angle measured with the center-head to center-base method was reduced from −16.1° (range −35° to −8°) to 5.1° (range −15° to 21°). The intermetatarsal angle increased from 5.8° (0–11°) t o 10.5° (0–19°). All patients were subjectively satisfied with the procedure. Our results indicate that joint preserving operation techniques are viable methods in the correction of mild and moderate symptomatic hallux varus deformities. Mild remaining varus deformities are well tolerated. In case of severe varus deformity or major signs of osteoarthritis in the first metatarsophalangeal joint MTP arthrodesis provides good results.
Bone marrow edema syndrome (BMES) is a common cause of severe bone and joint pain. Intra-articular migrating of bone marrow edema syndrome (BMES) is a very unusual pattern of disease which has been previously described in only a few cases and may raise the suspicion of an aggressive disease. We reviewed 8 patients (4 female, 4 male) with unilateral BMES located in the knee. The patients were aged 39–56 years (mean 50.2). In all the patients bone marrow edema (BME) found in the primary magnetic resonance imaging (MR imaging) shifted within the same joint, i.e. from the medial to the lateral femoral condyle or to the neighboring bone. Conservative therapy including limited weight-bearing for a period of three weeks was provided for seven patients after initial detection of BMES and one patient underwent surgical core decompression twice. The final MR investigation performed on average 8 months after baseline (range, 7–11 months) showed full resolution of BMES in 6 patients. One patient had small residual edematous bone areas. No quadrant was newly affected. Improvement of the MR imaging pattern was correlated with the clinical outcome in all patients. The severity of effort-induced pain (VAS) was reduced from 7.5 (2.0–10.0) at baseline to 5.9 (2.4–7.9) after 3 months and to 0.6 (0–0.9) after the final examination. Pain at rest (VAS) diminished from 3.9 (1.5–7.8) to 2.8 (1.4–6.0) after 3 months and to 0 at the final follow-up. All patients became asymptomatic after a mean of 9 months (6–11). Intra-articular migrating BMES is a condition seen very rarely. The disease is self-limited so that conservative therapy can be recommended.
Bone marrow edema syndrome (BMES) of the femoral head in pregnant women is a very rarely seen disease with disabling pain in the hip, beginning in the second or third trimester and persisting after parturition. Although isolated BMES is generally considered to be a self-limiting disease, progression to irreversible avascular necrosis of the femoral head has occasionally been observed. The conservative standard treatment of BMES consists of analgesic or anti-inflammatory medication combined with reduced weight bearing and physiotherapy. Better results regarding pain reduction are achieved by surgical intervention, with core decompression being the current standard technique for the management of BMES. The patients were aged between 31 and 43 years (mean 37.5 years). All patients presented with pain on effort, with gait disturbance and pain at rest starting in the third trimester of pregnancy at a mean gestational age of 28 weeks (25 to 32 weeks). Symptoms rapidly progressed over a 2-week period. We treated 4 postpartal women (6 hips) presenting femoral head BMES with infusions of the prostacycline analogue iloprost (20 μg for 5 days) followed by 3 weeks of partial weight-bearing. MRI was used to investigate the outcome of BMES. Symptoms regressed rapidly during and after therapy. After 4 weeks all patients were asymptomatic with no limitations in ambulation. In the MRI assessment, complete regression of BMES could be detected in three patients and minor residual BMES in the femoral neck of one patient (one hip) after 3 months. Pain did not recur in any patient at a mean follow-up of 31 months (14–43 months). The vasoactive drug iloprost has good analgesic potency in the treatment of postpartal women suffering from BMES and accelerates the natural course of the disease.
For surgical treatment of hallux rigidus many different procedures have been described. Resection arthroplasty (‘Keller procedure’) is a surgical procedure mostly used for older patients suffering from severe osteoarthritis of the first metatarsophalangeal joint. As a modification of this procedure, resection arthroplasty is combined with cheilectomy and interposition of the dorsal capsule and extensor hallucis brevis tendon, which are then sutured to the flexor hallucis brevis tendon on the plantar side of the joint (capsular interposition arthroplasty, IA). Capsular interposition arthroplasty was performed on 22 feet of 14 patients (six male, eight female) suffering from osteoarthritis of the 1st MTP-joint were included in this study (group 1). These results were compared to the outcome of 30 feet of 22 patients (12 male, 10 female) treated with resection arthroplasty (group 2). The indication for resection arthroplasty were the same as for IA. The mean age was 55.3 years (37.6 to 71.2) in group 1 and 57.8 (43.5 to 75.6) in group 2. The age distribution of our patients at surgery did not differ significantly between both groups (p=0.633). The mean follow-up period was 15.1 month, range 6 to 27 months and did not differ between both groups (group 1: 16.5 month, group 2: 14.1 month; p=0.143). The mean follow-up period was 15 months. No statistically significant difference was found between both groups concerning patient’s satisfaction, clinical outcome and increase in range of motion of the first metatarsophalangeal joint. At follow-up, patients who had undergone interposition arthroplasty did not show statistically significant better AOFAS forefoot-scores compared to the Keller procedure group. A high rate of osteonecrosis of the first metatarsal head was found in both groups. These radiological findings did not correlate with the clinical outcome at follow-up. There is no benefit in clinical or radiological outcome for capsular interposition arthroplasty compared to the Keller procedure.
Bone marrow edema (BME) is frequently observed on MR images in patients presenting with severe joint pain and may be present in numerous bone and joint diseases. BME may be subdivided into ischemic (bone marrow edema syndrome, BMES), mechanical and reactive BME. Although bone marrow edema of the knee is a common phenomenon, physical tests to diagnose this condition have not been investigated thus far. We hypothesized that a mallet test would be useful as a diagnostic aid as well as a screening tool. 70 patients (36 female, 34 male) were investigated in this blinded controlled study. Group 1 consisted of patients with painful BME in the knee and group 2 of patients with a painful knee without BME. Pain provoked by a reflex mallet was assessed for each quadrant on a visual analog scale (VAS). The VAS score was 3.7 (±2.1 cm) for quadrants affected by BME (group 1), 1.59 (±1.44) in non-affected quadrants of the knee affected by BME (group 1) and, 0.85 (±0.85) in painful knees without BME (group 2). Pain on the tapping test was significantly correlated with the presence of BME in the affected knee (p<
0.0001) as well as the affected quadrant (p<
0.0001 for the medial femoral condyle and the medial femoral plateau). The probable mode of action is that high intramedullary pressure in the BME affected bone (normal values are less than 30 mmHg) is additionally raised for a short period of time by the impact of the hammer on the bone surface, causing intense local pain. The test is economical, easy to perform in a doctor’s office, and not time-consuming but the final and evidentiary dignosis of BME can only be made by MRI. The tapping test is a good screening instrument to diagnose BME in the knee.
Bone marrow edema (BME) is a rare cause of pain in the foot. We reviewed 19 patients with unilateral bone marrow edema of ischemic, stress or osteoarthritic origin located in the hindfoot treated with the vasoactive prostacyclin analogue iloprost. The patients’ mean age was 61,5 years (25–76) and the duration of symptoms lasted 19 weeks before the therapy started. Bone marrow edema was located 9x in the talus, 3x in the calcaneus, 3x in the navicular bone and 2x in the cuboid. 11 cases were estimated to have a primary ischemic origin, the other 8 ones to be secondary to an activated osteoarthritis or to mechanic stress. Our therapy consisted of a series of five infusions with 20 μg (50 μg in the first six patients) of iloprost given over 6 hours on 5 consecutive days each. Mazur’s foot score was used to assess function before and 3 months after therapy. During this time, the score improved from a mean of 54,9 (range 23–73) before to 87,8 points (47–100) 3 months after therapy, with the best results in ischemic lesions with an improvement from 56,2 to 93,9 points and inferior results in patients with osteoarthritic edema as well as edema due to stress with a change in the score from 53 to 79,3 points. Magnetic resonance imaging showed complete recovery of the bone marrow edema within 3 months in 12 patients, 3x partial regression and no change in 4 cases with bone marrow edema due to activated osteoarthritis. We conclude that the parenteral application of the vasoactive drug iloprost might be a viable method in the treatment of bone marrow edema of different origins but especially in ischemic ones. In edema secondary to osteoarthrosis or stress, therapy effect with iloprost is of a symptomatic character depending on the grade of the basic disease.
