Turf toe: anatomy, diagnosis, and treatment

Context:

Despite an increasing awareness of turf toe injury, confusion still exists regarding the anatomy, mechanism, diagnosis, and treatment of this hyperextension injury to the hallux metatarsophalangeal (MTP) joint.

Evidence Acquisition:

This article reviews the anatomy, diagnosis, and treatment algorithm for turf toe injury by reviewing relevant studies and presenting information useful to clinicians, therapists, and athletic trainers. A literature search was performed by a review of PubMed and OVID articles published from 1976 to July 2010.

Results:

Grade I injury is a sprain or attenuation of the plantar capsular ligamentous complex of the hallux MTP joint; athletes are typically able to return to play as tolerated. Grade II injury is a partial rupture of the plantar soft tissue structures of the hallux MTP joint, typically requiring about 2 weeks to recover. Grade III injury is a complete rupture of the plantar structures of the hallux MTP joint, requiring at least 10 to 16 weeks to recover. Some complete ruptures require surgical repair.

Conclusion:

With accurate diagnosis, athletes can have an appropriate treatment plan, and their expectations can be tempered to the degree of injury. Careful management may allow successful return to play at a preinjury level of participation.

Incidence of re-amputation following partial first ray amputation associated with diabetes mellitus and peripheral sensory neuropathy: a systematic review

Diabetes mellitus with peripheral sensory neuropathy frequently results in forefoot ulceration. Ulceration at the first ray level tends to be recalcitrant to local wound care modalities and off-loading techniques. If healing does occur, ulcer recurrence is common. When infection develops, partial first ray amputation in an effort to preserve maximum foot length is often performed. However, the survivorship of partial first ray amputations in this patient population and associated re-amputation rate remain unknown. Therefore, in an effort to determine the actual re-amputation rate following any form of partial first ray amputation in patients with diabetes mellitus and peripheral neuropathy, the authors conducted a systematic review. Only studies involving any form of partial first ray amputation associated with diabetes mellitus and peripheral sensory neuropathy but without critical limb ischemia were included. Our search yielded a total of 24 references with 5 (20.8%) meeting our inclusion criteria involving 435 partial first ray amputations. The weighted mean age of patients was 59 years and the weighted mean follow-up was 26 months. The initial amputation level included the proximal phalanx base 167 (38.4%) times; first metatarsal head resection 96 (22.1%) times; first metatarsal-phalangeal joint disarticulation 53 (12.2%) times; first metatarsal mid-shaft 39 (9%) times; hallux fillet flap 32 (7.4%) times; first metatarsal base 29 (6.7%) times; and partial hallux 19 (4.4%) times. The incidence of re-amputation was 19.8% (86/435). The end stage, most proximal level, following re-amputation was an additional digit 32 (37.2%) times; transmetatarsal 28 (32.6%) times; below-knee 25 (29.1%) times; and LisFranc 1 (1.2%) time. The results of our systematic review reveal that one out of every five patients undergoing any version of a partial first ray amputation will eventually require more proximal re-amputation. These results reveal that partial first ray amputation for patients with diabetes and peripheral sensory neuropathy may not represent a durable, functional, or predictable foot-sparing amputation and that a more proximal amputation, such as a balanced transmetatarsal amputation, as the index amputation may be more beneficial to the patient. However, this remains a matter for conjecture due to the limited data available and, therefore, additional prospective investigations are warranted.

The effect of foot structure on 1st metatarsophalangeal joint flexibility and hallucal loading

The purpose of our study was to examine 1st metatarsophalangeal (MTP) joint motion and flexibility and plantar loads in individuals with high, normal and low arch foot structures. Asymptomatic individuals (n=61), with high, normal and low arches participated in this study. Foot structure was quantified using malleolar valgus index (MVI) and arch height index (AHI). First MTP joint flexibility was measured using a specially constructed jig. Peak pressure under the hallux, 1st and 2nd metatarsals during walking was assessed using a pedobarograph. A one-way ANOVA with Bonferroni-adjusted post hoc comparisons was used to assess between-group differences in MVI, AHI, early and late 1st MTP joint flexibility in sitting and standing, peak dorsiflexion (DF), and peak pressure under the hallux, 1st and 2nd metatarsals. Stepwise linear regression was used to identify predictors of hallucal loading. Significant between-group differences were found in MVI (F(2,56)=15.4, p<0.01), 1st MTP late flexibility in sitting (F(2,57)=3.7, p=0.03), and standing (F(2,57)=3.7, p=0.03). Post hoc comparisons demonstrated that 1st MTP late flexibility in sitting was significantly higher in individuals with low arch compared to high arch structure, and that 1st MTP late flexibility in standing was significantly higher in individuals with low arch compared to normal arch structure. Stepwise regression analysis indicated that MVI and 1st MTP joint early flexibility in sitting explain about 20% of the variance in hallucal peak pressure. Our results provide objective evidence indicating that individuals with low arches show increased 1st MTP joint late flexibility compared to individuals with normal arch structure, and that hindfoot alignment and 1st MTP joint flexibility affect hallucal loading.

Functional Results and Patient Satisfaction of First Metatarsophalangeal Joint Arthrodesis Using Dual Crossed Screw Fixation

A total of 262 feet in 228 consecutive patients underwent first metatarsophalangeal joint (MPJ) fusion; thus, the present study is the largest single-surgeon patient series reported. The inclusion criteria included severe painful deformity of the first MPJ due to osteoarthritis, rheumatoid arthritis, or gouty arthritis and stage 3 or 4 hallux rigidus. The exclusion criteria were revision surgery of the first MPJ, fixation other than with dual crossed screws, and a postoperative follow-up period of <3 months. Fusion of the first MPJ was fixated with dual-crossed 3.0-mm screws. The office follow-up period was ≥3 months postoperatively and the survey follow-up period was ≥6 months postoperatively. The mean duration to radiographic evidence of arthrodesis was 7.00 ± 2.33 weeks, and 252 of the feet (96.18%) achieved successful arthrodesis. The mean postoperative office follow-up duration was 30.43 ± 6.59 weeks. The mean modified American College of Foot and Ankle Surgeons scale score was 51.2 ± 3.28 of maximum possible of 68 points. The mean subjective score was 37.1 ± 2.5 (maximum possible of 50 points), and the mean objective score was 14.5 ± 1.7 (maximum possible of 18 points). Furthermore, 200 patients (87.72%) reported that they had little to no pain, 187 (82.02%) reported they either mostly liked the appearance of their toe or liked it very much, and 173 (75.88%) reported that they could wear any type of shoe most or all the time after the operation. Of the respondents, 207 (90.79%) stated they would have the surgery repeated, and 197 (86.40%) would recommend the surgery to a family member or friend.

Treatment of Progressive First Metatarsophalangeal Hallux Valgus Deformity: A Biomechanically Based Muscle-Strengthening Approach

Synopsis Hallux valgus is a progressive deformity of the first metatarsophalangeal joint that changes the anatomy and biomechanics of the foot. To date, surgery is the only treatment to correct this deformity, though the recurrence rate is as high as 15%. This clinical commentary provides instruction in a strengthening approach for treatment of hallux valgus deformity, by addressing the moment actions of 5 muscles identified as having the ability to counter the hallux valgus process. Unlike surgery, muscle strengthening does not correct the deformity, but, instead, reduces the pain and associated gait impairments that affect the mobility of people who live with the disorder. This review is organized in 4 parts. Part 1 defines the terms of foot motion and posture. Part 2 details the anatomy and biomechanics, and describes how the foot is changed with deformity. Part 3 details the muscles targeted for strengthening; the intrinsics being the abductor hallucis, adductor hallucis, and the flexor hallucis brevis; the extrinsics being the tibialis posterior and fibularis longus. Part 4 instructs the exercise and reviews the related literature. Instructions are given for the short-foot, the toe-spread-out, and the heel-raise exercises. The routine may be performed by almost anyone at home and may be adopted into physical therapist practice, with intent to strengthen the foot muscles as an adjunct to almost any protocol of care, but especially for the treatment of hallux valgus deformity. J Orthop Sports Phys Ther 2016;46(7):596-605. Epub 6 Jun 2016. doi:10.2519/jospt.2016.6704.

Gait Analysis of Foot Compensation After Arthrodesis of the First Metatarsophalangeal Joint

BACKGROUND

Arthrodesis of the first metatarsophalangeal (MTP1) joint is an intervention often used in patients with severe MTP1 joint osteoarthritis and relieves pain in approximately 80% of these patients. The kinematic effects and compensatory mechanism of the foot for restoring a more normal gait pattern after this intervention are unknown. The aim of this study was to clarify this compensatory mechanism, in which it was hypothesized that the hindfoot and forefoot would be responsible for compensation after an arthrodesis of the MTP1 joint.

METHODS

Gait properties were evaluated in 10 feet of 8 patients with MTP1 arthrodesis and were compared with 21 feet of 12 healthy subjects. Plantar pressures and intersegmental range of motion were measured during gait by using the multisegment Oxford Foot Model. Pre- and postoperative X-rays of the foot and ankle were also evaluated.

RESULTS

The MTP1 arthrodesis caused decreased eversion of the hindfoot during midstance, followed by an increased internal rotation of the hindfoot during terminal stance, and ultimately more supination and less adduction of the forefoot during preswing. In addition, MTP1 arthrodesis resulted in a lower pressure time integral beneath the hallux and higher peak pressures beneath the lesser metatarsals. A mean dorsiflexion fusion angle of 30 ± 5.4 degrees was observed in postoperative radiographs.

CONCLUSION

This study demonstrated that the hindfoot and forefoot compensated for the loss of motion of the MTP1 joint after arthrodesis in order to restore a more normal gait pattern. This resulted in a gait in which the rigid hallux was less loaded while the lesser metatarsals endured higher peak pressures. Further studies are needed to investigate whether this observed transfer of load or a preexistent decreased compensatory mechanism of the foot can possibly explain the disappointing results in the minority of the patients who experience persistent complaints after a MTP1 arthrodesis.

LEVEL OF EVIDENCE

Level III, comparative series.

Does First Ray Amputation in Diabetic Patients Influence Gait and Quality of Life?

It has recently been suggested that first ray amputation in diabetic patients with serious foot complications can prolong bipedal ambulatory status, and reduce morbidity and mortality. However, no data are available on gait analysis and quality of life after this procedure. In the present case-control study (6 amputee and 6 nonamputee diabetics, 6 healthy non-diabetic), a sample of amputee diabetic patients were evaluated and compared with a sample of nonamputee diabetic patients and a group of age-matched healthy subjects. Gait biomechanics, quality of life, and pain were evaluated. Compared with the other 2 groups, amputee patients displayed a lower walking speed and greater variability and lower ankle, knee, and hip range of motion values. They also tended to have a more flexed hip profile. Pain and lower quality of life were related to worsening biomechanical data. Our study results have shown that gait biomechanics in diabetic patients with first ray amputation are abnormal, probably owing to the severity of diabetes and the absence of the push-off phase provided by the hallux. Tailored orthotics and rehabilitation programs and a specific pain management program should be considered to improve the gait and quality of life of diabetic patients with first ray amputation.

Conservative Surgical Treatment of Infected Ulceration of the First Metatarsophalangeal Joint With Osteomyelitis in Diabetic Patients

Ulceration of the plantar aspect of the first metatarsophalangeal joint is a common localization in the diabetic foot. Conservative treatment of this lesion is a challenging problem, performed through the soft tissues and osseous debridement. The present study included a cohort of 28 patients affected by diabetes mellitus and a first ray lesion penetrating the bone. After surgical debridement with removal of the infected bone, we positioned antibiotic-loaded bone cement and stabilized the treated area with an external fixator. All patients with critical limb ischemia had their vascular disease treated before the procedure. The mean follow-up was 12.2 ± 6.9 months. Four patients developed a relapse of the ulceration after the procedure. In the postoperative period, 1 patient (3.57%) developed dehiscence of the surgical site and underwent a second procedure. In the follow-up period, 2 patients (7.14%) experienced bone cement dislocation. In 1 of these patients, a new ulceration was observed dorsally to the surgical site. The approach was surgical revision with bone cement replacement and stabilization with a new external fixator. In the other patient, given the absence of ulcerations, the cement was removed, and arthrodesis with internal stabilization using 2 cannulated screws was performed. One patient (3.57%), who had developed a relapse of ulceration after recurrent critical ischemia, underwent a percutaneous revascularization procedure and transmetatarsal amputation. During the follow-up period, no ulceration recurrences, transfer ulcerations, shoe fit problems, or gait abnormalities were detected in the other 24 patients. Our study presents the results of a technique requiring a 1-stage surgical approach to a relatively common problem, which is often difficult to solve.

Comparison of Complication and Reoperation Rates for Minimally Invasive Versus Open Cheilectomy of the First Metatarsophalangeal Joint

BACKGROUND

Dorsal cheilectomy of the first metatarsophalangeal joint is an accepted treatment to alleviate dorsal impingement, pain, and reduced dorsiflexion in hallux rigidus. Traditionally performed via an open incision, this procedure has more recently been performed using minimally invasive techniques despite limited supportive published evidence.

METHODS

From December 2012 through December 2017, a retrospective analysis of all cheilectomies performed in our institution was done. The surgical technique was recorded along with any subsequent procedures performed for either persistent or recurrent pain, and complications were also noted. A comparison between open and minimally invasive outcomes was performed. In total, 171 cheilectomies were performed during this period. There were 38 open and 133 minimally invasive procedures.

RESULTS

At a mean 3-year follow-up, the reoperation rates of the 2 groups were different with only 1 (2.6%) of the open group requiring a fusion, while 17 (12.8%) of the minimally invasive surgical (MIS) group required further surgery (relative risk, 4.86; P = .059). In the open group, there was 1 (2.6%) complication, compared with 15 (11.3%) in the minimally invasive group (relative risk, 4.29; P = .076).

CONCLUSION

While patients may opt for MIS cheilectomy with a proposed faster recovery time and better cosmesis, they should be counseled about the risks and benefits of both methods, and that the technique of MIS cheilectomy utilized in this study appears to have an increased relative risk of requiring a further procedure.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

Accurate Measurement of First Metatarsophalangeal Range of Motion in Patients With Hallux Rigidus

BACKGROUND

The reliability of range of motion (ROM) measurements has not been established for the hallux metatarsophalangeal (MTP) joint in patients with hallux rigidus. The aim of the present study was to prospectively assess the clinical versus radiographic difference in ROM of the arthritic hallux MTP joint.

METHOD

One hundred consecutive patients who presented with any grade of hallux rigidus were included in this prospective study to determine the hallux MTP range of motion. Clinical range of motion using a goniometer and radiographic range of motion on dynamic x-rays was recorded.

RESULTS

The mean difference between clinical and radiographic dorsiflexion was 13 degrees (P < .001). For all measurements, clinical dorsiflexion was equal to or less than radiographically measured dorsiflexion. The difference was significantly greater in patients with a clinical dorsiflexion of less than 30 degrees than in patients with 30 degrees or more. Radiographic measurement of hallux dorsiflexion had an excellent intra- and interobserver reliability.

CONCLUSION

We describe a reliable, reproducible, and straightforward method of measuring hallux MTP ROM that improved upon measuring clinical ROM.

LEVEL OF EVIDENCE

Level II, prospective comparative study.

Second-Generation Ceramic First Metatarsophalangeal Joint Replacement for Hallux Rigidus

BACKGROUND

Ceramic first metatarsophalangeal (MP) joint replacement has been reported for treatment of hallux rigidus, but there are no published mid- or long-term studies available. We present our midterm results using a second-generation ceramic first MP joint implant.

METHODS

A retrospective review of clinical data and radiographs was performed for 31 feet (24 women; mean age at surgery, 55 ± 6 years) who had first MP joint replacement with a second-generation ceramic prosthesis (primary, 29 feet; revision, 2 feet). Mean follow-up was 81 ± 27 months after surgery

RESULTS

Mean first MP passive range of motion was 32 ± 17 degrees (dorsi- and plantarflexion). Mean AOFAS score was 72 ± 19 points and Foot Function Index was 27 ± 26 points (all 31 feet). Clinical rating for 29 feet that had surgery as a primary procedure was excellent in 5 feet (17%), good in 8 feet (28%), fair in 3 feet (10%), and poor in 13 feet (45%). Patients were satisfied with the outcome in 24 feet (77%). Follow-up radiographs showed that radiolucency, change in angulation, sinkage, and malalignment of the metatarsal or proximal phalanx components were common. Complications included 1 superficial wound infection, and revision was performed in 5 feet (16%) because of loosening, sinkage, subluxation, pain, or fractured prosthesis. Implant survival was 92% at 5 years, 85% at 7 years, and 68% at 9 years.

CONCLUSION

The results of second-generation ceramic first MP joint replacement in our series demonstrated poor clinical and radiological results with a high revision rate.

LEVEL OF EVIDENCE

Level IV, case series.

Fractures of the hallux in children

BACKGROUND

Foot fractures account for 5% to 13% of pediatric fractures. Fractures of the hallux require special attention due to its role in weight bearing, balance, and pedal motion. In this study, a large series of children with hallux fractures is presented.

METHODS

All children treated with fractures of the hallux between June 2004 and December 2011 were included. The medical records were analyzed and X-rays were reviewed. The fractures were classified according to their anatomic location and the type of fracture. Three hundred seventeen patients (mean age = 11.7 years; range, 1-18 years; 65% male) sustained a fracture of the hallux.

RESULTS

Most accidents (28%) occurred at sports facilities, and soccer was the most common cause of a fracture of the hallux (28%). Closed injuries were diagnosed in 92% of the patients; 8% of the children presented with open fractures. In 144 children, the growth plate was affected. Fifty-nine patients presented with diaphyseal fractures, 42 patients with osseous avulsions, and 40 patients with fractures of the distal part of the phalanx. Nineteen children had incomplete and 13 patients comminuted fractures. The vast majority of the children (86%) were treated conservatively. Operative interventions were required in 14% of the patients. Good outcome was achieved in both conservatively and operatively treated patients.

CONCLUSION

In children, fractures of the hallux were most often caused by ball sports and had a good prognosis. The vast majority of these fractures could be treated conservatively yielding good outcome.

LEVEL OF EVIDENCE

Level IV, case series.

Operative Outcomes of Grade 3 Turf Toe Injuries in Competitive Football Players

BACKGROUND

Turf toe is a term used to describe a hyperextension injury to the first metatarsophalangeal joint. Although the vast majority of turf toe injuries can be treated successfully without operative intervention, there are instances where surgery is required to allow the athlete to return to play. Although there is a plethora of literature on turf toe injuries and nonoperative management, there are currently few reports on operative outcomes in athletes.

METHODS

We obtained all cases of turf toe repair according to the ICD-10 procedural code. The inclusion criteria included: age greater than 16, turf toe injury requiring operative management and at least a varsity level high school football player. The charts were reviewed for age, BMI, level of competition, injury mechanism, football position, setting of injury and playing surface. In addition, we recorded the specifics of the operative procedure, a listing of all injured structures, the implants used and the great toe range of motion at final follow-up visit. The AOFAS Hallux score and VAS was used postoperatively as our outcome measures. Our patient population included 15 patients. The average follow-up time was 27.5 months.

RESULTS

The average patient was 19.3 years old with a body mass index of 32.3. The average playing time missed was 16.5 weeks. The average dorsiflexion range of motion at the final follow-up was 42.3 degrees. At final follow-up, the average AOFAS Hallux score was 91.3. The average VAS pain score was 0.7 at rest and 0.8 with physical activity.

CONCLUSION

Complete turf toe injuries are often debilitating and may require operative management to restore a pain-free, stable, and functional forefoot. This study represents the largest cohort of operatively treated grade 3 turf toe injuries in the literature and demonstrates that good clinical outcomes were achieved with operative repair.

LEVEL OF EVIDENCE

Level IV, case series.

First Metatarsal Head Osteochondral Defect Treatment With Particulated Juvenile Cartilage Allograft Transplantation: A Case Series

BACKGROUND

Focal damage to articular cartilage, also called an osteochondral defect (OCD), can be a cause of pain and decreased range of motion. Recent advancements have led to transplantation techniques using particulated juvenile articular cartilage allograft. This technique has been applied to the first metatarsal head to a very limited degree, with no published results to our knowledge. The aim of this study was to review the clinical results of patients who underwent particulated juvenile cartilage allograft implantation for first metatarsal head OCDs.

METHODS

We performed a retrospective consecutive case series study. Nine patients, at an average age of 41 years, were treated for symptomatic focal osteochondral defects of the first metatarsal head with particulate cartilage grafting from 2010 to 2016. Patients were contacted by phone to assess interest in returning to the office for follow-up, where weightbearing radiographs of the foot were obtained and a foot examination was performed.

RESULTS

At an average follow-up of 3.3 years, 7 of 9 patients reported no pain with recreational activities and no patient required further operations. This patient cohort was physically active, with 6 of 9 listing running as a regular activity. The average overall American Orthopaedic Foot & Ankle Society (AOFAS) Hallux Metatarsophalangeal-Interphalangeal Scale questionnaire score was 85 (maximum 100), AOFAS pain 35.6 (maximum 40), and AOFAS function 40.1 (maximum 45). Patient satisfaction surveys correlated with the AOFAS scores and revealed that 7 of 9 patients were very satisfied with their results, 1 was satisfied, and 1 patient was very dissatisfied.

CONCLUSION

Particulated juvenile cartilage allograft transplantation is a promising treatment option for symptomatic first metatarsophalangeal focal articular cartilage lesions. Further study is needed to demonstrate which lesions respond better to this type of cartilage graft versus traditional marrow-stimulating procedures.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

The Central Role of Small Vertical Substrates for the Origin of Grasping in Early Primates

The manual and pedal grasping abilities of primates, characterized by an opposable hallux, flat nails, and elongated digits, constitute a unique combination of features that likely promoted their characteristic use of arboreal habitats. These hand and foot specificities are central for understanding the origins and early evolution of primates and have long been associated with foraging in a fine-branch milieu. However, other arboreal mammals occupy similar niches, and it remains unclear how substrate type may have exerted a selective pressure on the acquisition of nails and a divergent pollex/hallux in primates or in what sequential order these traits evolved. Here, we video-recorded 14,564 grasps during arboreal locomotion in 11 primate species (6 strepsirrhines and 5 platyrrhines) and 11 non-primate arboreal species (1 scandentian, 3 rodents, 3 carnivorans, and 4 marsupials). We quantified our observations with 19 variables to analyze the effect of substrate orientation and diameter on hand and foot postural repertoire. We found that hand and foot postures correlate with phylogeny. Also, primates exhibited high repertoire diversity, with a strong capability for postural adjustment compared to the other studied groups. Surprisingly, nails do not confer an advantage in negotiating small substrates unless the animal is large, but the possession of a grasping pollex and hallux is crucial for climbing small vertical substrates. We propose that the divergent hallux and pollex may have resulted from a frequent use of vertical plants in early primate ecological scenarios, although nails may not have resulted from a fundamental adaptation to arboreal locomotion.

Endoscopic adhesiolysis of the flexor hallucis longus muscle

Flexor hallucis longus muscle can adhere to the distal tibia after tibial fracture. The patient may complain of deep posteromedial ankle pain, checkrein deformity of the hallux, hallux flexus or development of hallux rigidus. Surgical treatment of release of the FHL muscle or lengthening of the FHL tendon has been proposed. We described an endoscopic approach of release of the FHL muscle from the distal tibia with the advantage of minimal soft tissue dissection.

LEVEL OF EVIDENCE

Therapeutic Level V: Expert Opinion/Technique.

Fusion of the First Metatarsophalangeal Joint: Precontoured or Straight Plate?

Precontoured, low-profile plates with fixed dorsiflexion angles are becoming increasingly popular for first metatarsophalangeal joint fusion. We have concerns that the routine use of a precontoured plate can lead to excessive clinical dorsiflexion. The aim of our study was to investigate the relationship between the first metatarsophalangeal joint dorsiflexion intramedullary angle and the angle formed at the dorsal cortices where the plate is applied. We hypothesized that the dorsal cortical angle was significantly less dorsiflexed than the intramedullary angle. We measured both angles on lateral weightbearing radiographs of 40 consecutive individuals presenting with forefoot symptoms. The results demonstrated that the mean dorsal cortical angle was significantly smaller (mean 0.2° plantarflexion) compared with the intramedullary angle (mean 10.6° dorsiflexion; p < .001). The interobserver and intraobserver reliability of both the intramedullary and the dorsal cortical measurements was very good. In conclusion, the dorsal cortical angle is, on average, 10.8° smaller than the intramedullary angle, with a mean angle of almost 0°. This finding should be considered when selecting plates for first metatarsophalangeal joint fusion.

Early Weight-Bearing After Arthrodesis of the First Metatarsal-Phalangeal Joint: A Systematic Review of the Incidence of Non-Union

Arthrodesis of the first metatarsal-phalangeal joint is a reliable procedure for correction of both hallux limitus/rigidus and severe hallux abducto valgus deformities. However, 1 potential contraindication to the procedure is the extended period of non-weight-bearing immobilization that is typically associated with the postoperative course. The objective of this investigation was to perform a systematic review of the incidence of non-union after early weight bearing in patients who underwent arthrodesis of the first metatarsal-phalangeal joint. We performed a review of electronic databases with the inclusion criteria of retrospective case series, retrospective clinical cohort analyses, and prospective clinical trials with n ≥ 15 feet, a mean follow-up of ≥12 months, a defined postoperative early weight-bearing protocol (defined as ≤2 weeks), a clear description of the fixation construct, a reported incidence rate of non-union, and patients who underwent primary surgery for hallux abducto valgus or hallux limitus/rigidus deformities. Seventeen studies met our inclusion criteria, with a total of 898 feet analyzed. Of these, 57 (6.35%) were described as developing a non-union. This would likely be considered an acceptable crude, heterogeneous incidence of non-union when considering this procedure. It might also indicate that arthrodesis of the first metatarsal-phalangeal joint does not always require an extended period of non-weight-bearing postoperative immobilization.

First Metatarsophalangeal Joint Arthrodesis Using an Intraosseous Post and Lag Screw With Immediate Bearing of Weight

Arthrodesis is the gold standard procedure for advanced arthrosis of the first metatarsophalangeal joint. Having a strong construct is preferable for allowing immediate bearing of weight, which facilitates patient rehabilitation. Plate and screw fixation is currently in favor but can lead to prominent metalware necessitating removal. The aim of this study is to report the results of a series of 54 first metatarsophalangeal joint arthrodeses performed in 52 patients treated with an implant composed of an intraosseous post and lag screw. All of the patients had a minimum follow-up of 1 year, and the indication for the surgery was end-stage hallux rigidus in 44 (81.5%) feet, severe hallux valgus in 8 (14.8%) feet, and rheumatoid arthritis in 2 (3.7%) feet. Arthrodesis was achieved in 52 (96.3%) feet at a mean of 61 ± 16 (range 39 to 201) days with nonunion observed in 2 (3.7%) feet; neither of the 2 patients had known risk factors. Metalware impinging on soft tissues necessitating removal was observed in 3 (5.6%) feet, and there were no cases of loss of position or implant breakage. The mean Manchester-Oxford Foot Questionnaire score improved from 46.4 ± 13.3 to 18.4 ± 9.4 (p < .001) at latest follow-up. In conclusion, our results suggest the intraosseous post and lag screw device was safe and effective, and it can be considered an alternative method of stabilizing the first metatarsophalangeal joint when undertaking arthrodesis surgery.

Ontogeny of hallucal metatarsal rigidity and shape in the rhesus monkey (Macaca mulatta) and chimpanzee (Pan troglodytes)

Life history variables including the timing of locomotor independence, along with changes in preferred locomotor behaviors and substrate use during development, influence how primates use their feet throughout ontogeny. Changes in foot function during development, in particular the nature of how the hallux is used in grasping, can lead to different structural changes in foot bones. To test this hypothesis, metatarsal midshaft rigidity [estimated from the polar second moment of area (J) scaled to bone length] and cross-sectional shape (calculated from the ratio of maximum and minimum second moments of area, Imax /Imin ) were examined in a cross-sectional ontogenetic sample of rhesus macaques (Macaca mulatta; n = 73) and common chimpanzees (Pan troglodytes; n = 79). Results show the hallucal metatarsal (Mt1) is relatively more rigid (with higher scaled J-values) in younger chimpanzees and macaques, with significant decreases in relative rigidity in both taxa until the age of achieving locomotor independence. Within each age group, Mt1 rigidity is always significantly higher in chimpanzees than macaques. When compared with the lateral metatarsals (Mt2-5), the Mt1 is relatively more rigid in both taxa and across all ages; however, this difference is significantly greater in chimpanzees. Length and J scale with negative allometry in all metatarsals and in both species (except the Mt2 of chimpanzees, which scales with positive allometry). Only in macaques does Mt1 midshaft shape significantly change across ontogeny, with older individuals having more elliptical cross-sections. Different patterns of development in metatarsal diaphyseal rigidity and shape likely reflect the different ways in which the foot, and in particular the hallux, functions across ontogeny in apes and monkeys.

Glomus tumor of the great toe

Glomus tumor is a rare mesenchymal neoplasm composed of cells that resemble the modified perivascular smooth muscle cells (glomus cells) of the normal glomus body. A glomus tumor can appear in any part of the body, although it mostly appears in the extremities, especially in the subungual area of the hand. It has been less commonly reported in the foot. A case of glomus tumor of the pulp of the hallux is described in the present report.

Outcomes of the Distal Metatarsal Dorsiflexion Osteotomy for Advanced Hallux Rigidus

BACKGROUND

Hallux rigidus can be treated using several different methods and the best treatment option depends on the severity of degenerative changes of the metatarsophalangeal (MTP) joint. However, the ideal operative option for advanced hallux rigidus remains debatable. This prospective study was performed to evaluate the intermediate-term clinical outcomes of distal metatarsal osteotomy used as a joint-preserving method for the treatment of advanced hallux rigidus.

METHODS

Forty-two cases (39 patients) were followed for more than 3 years after distal metatarsal dorsiflexion osteotomy for advanced hallux rigidus of grade III-IV. Clinical evaluations included the American Orthopaedic Foot & Ankle Society (AOFAS) scores, Foot and Ankle Ability Measure (FAAM) scores, and patient subjective satisfaction scores. Range of motion (ROM) of great toe, complications, reoperation rates, width of the MTP joint space, and times to union were evaluated.

RESULTS

Mean AOFAS hallux and mean FAAM scores significantly improved from 56.4 and 61.2 points preoperatively to 87.6 and 88.7 points at final follow-up, respectively ( P < .001). Grade III and IV groups had significantly different AOFAS and FAAM scores at final follow-up. Mean dorsiflexion of great toe significantly improved from 14.8° preoperatively to 35.5° at final follow-up ( P < .001). Mean patient satisfaction score at final follow-up was 92.8 points. There were 4 cases (9.5%) of subsequent fusion and 2 cases (4.8%) of transfer metatarsalgia.

CONCLUSIONS

Distal metatarsal dorsiflexion osteotomy using bio-compression screws appears to be an effective operative option for grade III advanced hallux rigidus with viable cartilage on >50% of the first metatarsal articular surface, as it restored joint motion, provided reliable pain relief, and did not require implant removal. However, based on the unsatisfactory clinical results and the high rate of reoperation observed, the authors cannot recommend this operative method for the treatment of end-stage (grade IV) hallux rigidus.

LEVEL OF EVIDENCE

Level IV, prospective case series.

American Orthopedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal Joint Scale: A Cross-Cultural Adaptation and Validation Study in the Persian Language

We evaluated the reliability and validity of the Persian translation of the American Orthopedic Foot and Ankle Society hallux metatarsophalangeal-interphalangeal joint scale (AOFAS Hallux MTP-IP). The translated AOFAS Hallux MTP-IP scale form was completed for 101 patients with hallux deformities; the subjective questions were answered by the patients, whereas the orthopedic foot and ankle surgeon and his assistant answered the objective questions. The validated Persian version of the 36-Item Short Form Survey Instrument (SF-36) was used for validity assessment. Eighty-five females and 16 males with a mean age of 49 years were enrolled. Hallux valgus and hallux rigidus was the diagnosis in 73 and 28 patients, respectively. Intrarater reliability had a high level of correlation (rho >0.6) for all subscales and total score. Although the correlation between the total score of the AOFAS Hallux MTP-IP scale and role: physical subscale of SF-36 was the highest (rho = 0.47), the total score of AOFAS Hallux MTP-IP scale and the other 7 domains of SF-36 had a correlation ranging between -0.17 and 0.43. Moreover, the correlation between total score of AOFAS-Hallux MTP-IP and SF-36 physical component summary scale was 0.50, which was higher than the correlation between total score of AOFAS and SF-36 mental component summary scale (rho = 0.35). Convergent validity was approved for MTP joint motion (0.59), IP joint motion (0.51), and callus (0.56) items of AOFAS-Hallux MTP-IP. Spearman's rank correlation coefficient between all items of the functional subscale of AOFAS Hallux MTP-IP scale with its own subscales was higher than the coefficient between these items and other subscales, including pain and alignment (discriminate validity). Floor and ceiling effects were calculated as 2% and 1%, respectively. Our findings indicate that the translated Persian version of the AOFAS Hallux MTP-IP scale is a reliable instrument, but its validity is not satisfactory.

Dislocation of the First Metatarsophalangeal Joint: A Case Report and Suggested Classification System

Dislocation of the first metatarsophalangeal joint is a relatively rare and still poorly known injury. The current classification includes only the dorsal variety of this lesion; thus, as further cases of other varieties are reported, a larger understanding of this entity is required. We report the case of a young male with dorsal dislocation of the first metatarsophalangeal joint treated by closed reduction. The clinical outcome at the 2-year follow-up point is reported. A review of the published data of the variations of this injury reported to date is included, and a new summarizing classification is suggested.