The Role of the Flexor Hallucis Longus in the Treatment of the Painful Hallux Metatarsophalangeal Joint

BACKGROUND

Pain in the hallux metatarsophalangeal joint (MTPJ) is very common, yet the underlying etiology remains unknown. Previous clinical research and biomechanical research has implicated stenosing flexor hallucis longus (FHL) tendonitis as a possible cause. The hypothesis of this study was that treatment solely focusing on alleviating restricted FHL excursion would be beneficial in patients with hallux MTPJ pain.

METHODS

This is a retrospective study of those treated in the Foot & Ankle Division between January 2009, and December 2018, who were diagnosed with FHL tendonitis with associated pain in the hallux MTPJ. Demographics, comorbidities, examination findings, imaging results, pain scores, treatment instituted, and outcome was obtained from the electronic medical record. The primary outcome was the improvement in the pain score (visual analog scale [VAS]). The surgical patients were included if their procedure was solely related to the FHL (posteromedial ankle release ± os trigonum resection). The decision to have surgery was analyzed by univariate and multivariable statistics using demographics, comorbidities, and clinical findings as potential factors (P < .05).

RESULTS

In 75% (59 of 79 feet), nonoperative treatment of FHL stenosis resulted in a decrease in pain scores that the patients felt was satisfactory. The operative group that had an FHL release showed decreased pain in 90% (18 of 20 feet). Multivariable analysis identified the need for immobilization (OR 9.8, 95% CI 1.8-55.2, P = .009), participating in athletics (OR 8.7, 95% CI 1.8-42.2, P = .007), and higher initial VAS (OR 1.7, 95% CI 1.3-2.3, P < .001) as being associated with the decision for surgery.

CONCLUSION

Previous biomechanical studies have suggested that stenosing FHL synovitis can cause increased intraarticular loading in the hallux MTPJ. The current clinical study supports this hypothesis, demonstrating that treatment focused on relieving restricted FHL excursion can ameliorate pain in the hallux MTPJ in select cases.

A 3 month nutrition and exercise program improved hallux strength among senior daycare center users in Korea: a cluster randomized controlled trial

Introduction

With a growing aging population, the focus on the health and well-being of older adults, especially in preventing falls, becomes crucial. This 3 month study, initiated in July 2022, aimed to assess the impact of a nutrition and exercise program in senior daycare centers in Chuncheon, South Korea.

Methods

A 3 month study, beginning in July 2022, included 204 older adults from 10 senior daycare centers in Chuncheon, South Korea. Randomly assigned to intervention or control groups, the intervention involved nutrition, daily toe exercises, or both. Control centers received interventions post-measurements. Pre- and post-intervention analyses used paired t-tests and multiple linear regression, assessing metrics like toe grip strength for significance. While 204 were initially enrolled, the analysis included 151 participants due to dropouts.

Results

Participants, with a mean age of 83.3 years (43.1% aged ≥ 85 years), exhibited mild to moderate cognitive impairment and multiple chronic illnesses. Health data indicated that 37.3% were obese, and the average BMI was 24.0 kg/m2. Both the intervention and control groups showed significant improvements in toe grip strength post-intervention. Specifically, the exercise-only and combined exercise-nutrition groups demonstrated significant differences in hallux strength compared to the control group after adjusting for age and gender.

Conclusion

The study showed that a basic nutrition and exercise program increased toe strength in older adults with chronic diseases, including mild cognitive impairments. This intervention holds potential to prevent muscle strength decline and reduce fall risks in older individuals. As the first of its kind in Korean senior daycare centers, it emphasizes the need for future research and standardized programs for senior daycare users.

Analysis of Pain and Effectiveness in Digital Block of the First Toe Using Syringe vs. Carpule: Frost's H vs. Modified Frost's H Randomized Clinical Trial

Background: Currently, there is no scientific evidence regarding pain in the anesthetic block of the first toe according to the method of application. However, clinical evidence has highlighted the use of the carpule due to the low pain it causes during the administration of the anesthetic. Most studies on anesthesia and pain, especially using the carpule and distraction methods, belong to the field of dentistry. Objective: To compare the pain and effectiveness between the anesthetic block of the first toe using a carpule and syringe with Frost's H technique and the modified Frost's H technique. Method: A total of 564 subjects were selected and divided into four groups. Subjects were subjected to experimental conditions (randomization through the Random Allocation Software program 2.0), and divided into group 1 = 138 subjects, corresponding to the block with syringe and Frost's H, group 2 = 141 subjects, corresponding to the syringe group and modified Frost's H, group 3 = 141 subjects, corresponding to the carpule group and modified Frost's H, and group 4 = 144 subjects, corresponding to the carpule group and Frost's H. The same researcher generated the random allocation sequence, enrolled the participants, and assigned them to the interventions. Each subject was unaware of the anesthetic procedure assigned by the researcher. Outcome parameters were pain after anesthetic infiltration and its effectiveness. Results: The anesthetic block with carpule showed a lower pain score compared to the anesthetic block with syringe (2.8 vs. 5.3; p < 0.001). However, when analyzing effectiveness, a higher efficacy rate was obtained in the anesthetic blocks performed using the modified Frost's H technique (97.5% vs. 88.1%; p < 0.001). Conclusions: The anesthetic block with carpule and the modified Frost's H technique is less painful and more effective than the traditional anesthetic block.

Hallux Flexion Deformity Secondary to Fibula Harvesting in a 10-Year-Old Patient With Neurofibromatosis

Hallux interphalangeal joint (IPJ) flexion contracture is an uncommon deformity with various underlying causes, including trauma, neurological disorders, and connective tissue pathologies. We present a unique case of a 10-year-old female patient with neurofibromatosis type 1 (NF1) and a history of fibula transposition surgery, resulting in a hallux IPJ flexion contracture. We believe that the loss of the proximal fibular attachment of the extensor hallucis longus (EHL) following fibula harvesting resulted in EHL weakness and unopposed flexor hallucis longus (FHL) pull that eventually led to the contracture. The patient underwent various diagnostic assessments, ruling out other potential causes of the deformity. This case emphasizes the importance of considering previous surgical interventions when encountering flexion contractures of the toes.

Nonunion After First Metatarsophalangeal Joint Arthrodesis: The Association With Shoe Size

INTRODUCTION

First metatarsophalangeal joint (MTPJ) arthrodesis is a common treatment for various foot conditions, with nonunion as a frequent complication. The incidence of nonunion varies widely in the literature. In particular, males have a higher risk of nonunion than females. This is possibly due to biomechanical and anatomical differences, as men have on average larger feet than women. This study therefore aims to explore whether shoe size, as a proxy for foot size, affects nonunion rates and could explain the gender disparity in nonunion rates.

METHODOLOGY

An exploratory analysis of retrospectively collected data from patients who underwent primary first MTPJ arthrodesis in a single secondary hospital between January 2012 and December 2019. Additional data on body weight, height, and shoe size were prospectively collected from patients.

RESULTS

Among 261 included patients, 57 (21.8%) experienced nonunion. Nonunion incidence was higher in males (18, 26.9%) than in females (39, 20.1%). Self-reported shoe size showed no significant association with nonunion in both univariate and multivariate analyses.

DISCUSSION

The study's findings suggest that shoe size, as a proxy for foot size, is not associated with nonunion after the first MTPJ arthrodesis. Despite observing a gender difference in nonunion rates, this disparity could not be explained by shoe size.

CONCLUSIONS

Shoe size as a proxy for foot size appears to have no clinical association with nonunion following the first MTPJ arthrodesis.

Incidence of Nonunion of the First Metatarsophalangeal Joint Arthrodesis After Failed Implant Arthroplasty: A Systematic Review

Joint arthroplasty of the first metatarsophalangeal (MTP) joint is an accepted surgical option for patients with hallux rigidus. However, this procedure has been reported to have a high complication rate and unpredictable survivorship. Implant arthroplasty failure is a devastating complication that results in significant osseous defect with altered biomechanics of the foot. Commonly, salvage options are limited to arthrodesis with bone grafting. However, outcomes are rarely reported. The purpose of this study is to investigate the fusion rates of first metatarsophalangeal joint arthrodesis after conversion from failed implant arthroplasty. A systematic review of electronic databases to find reports of conversion arthrodesis after failed implant arthroplasty was performed. Six studies involving a total of 76 patients with a weighted mean age of 54.9 met the inclusion criteria. Out of the 6 included articles, the nonunion rate was 16.5% at a weighted mean follow-up of 48.1 months. The nonunion rate in the current report is higher than reported nonunion rates of primary arthrodesis. More prospective studies with consistent and standard outcome measures are needed to further determine the success rate of this salvage procedure.Levels of Evidence: 4, Systematic Review of Level 4 Studies.

Infrequent Pediatric Subungual Injury Diagnosed by Intraoperative Anatomopathological Material: A Case Report

Subungual lesions are very common in clinical practice. We present the clinical case of a 10-year-old female patient who presented with progressive nail deformity. The onset of the condition was approximately five years prior to presentation with an injury in the left hallux, according to the mother. She denied pain or change in the color of the area from the onset of the injury to the day of consultation. There was no previous trauma. Examination revealed subungual bone injury to the distal extremity (distal phalanx of the left hallux), and imaging tests (X-ray and soft tissue ultrasound) found bone injury. Subungual exostosis was considered as a possible diagnosis, thus prompting the indication for exeresis of the tumoral process. After surgical removal, the resected specimen was sent for pathological assessment, which found that an intraosseous hemangiolymphangioma was the origin of the tumor. A subungual exostosis is a slow-growth benign osseous tumor mainly located in the distal phalanx of the hallux that especially affects young adults, being less frequent in children. This condition results from a process of bone neoformation involving different stages, the clinical symptoms of which depend on its size and associated processes. Hemangiolymphangiomas are angiomatous lesions of the blood and lymphatic vessels that have a controversial etiology and present slow, painless, and progressive growth; these lesions are mostly benign. It is worth emphasizing that subungual injuries are not always caused by an underlying bone; therefore, potential differential diagnoses, both benign and malignant, should be considered, based on the location of the injury.

Reliability and Validity of the Turkish Version of the American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal Joint Scale

BACKGROUND

The American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal (AOFAS Hallux MTP-IP) scale is one of the most widely used outcome measures to evaluate hallux pathologies. This study aimed to translate the AOFAS Hallux MTP-IP scale into Turkish and investigate its psychometric properties.

METHODS

The psychometric properties of the Turkish version of the AOFAS Hallux MTP-IP (AOFAS Hallux MTP-IP-T) scale were tested in 66 patients with hallux pathologies (52 women; mean age, 47.64 ± 12.75 years). Cronbach's alpha was used to assess internal consistency. The intraclass correlation coefficient (ICC) was used to estimate test-retest. Construct validity was analyzed with the Turkish version of the Manchester-Oxford Foot Questionnaire (MOXFQ), Visual Analogue Scale (VAS), and 12-item Short-Form Health Survey(SF-12).

RESULTS

The AOFAS Hallux MTP-IP-T scale had adequate internal consistency (α = 0.71) and test-retest reliability (ICC2,1 = 0.93 for pain, ICC2,1 = 0.97 for function, and ICC2,1 = 0.97 for total score). The AOFAS Hallux MTP-IP-T total score has a moderate to strong correlation with VAS-activity and MOXFQ (ρ = -0.77, P = .001; ρ = -0.69, P = .001, respectively). The weakest correlation was found between the AOFAS Hallux MTP-IP-T and the SF-12 mental component scale (ρ = 0.31, P = .01).

CONCLUSION

AOFAS Hallux MTP-IP-T has sufficient reliability and validity to evaluate Turkish-speaking individuals with a variety of forefoot pathologies including the hallux.

LEVELS OF EVIDENCE

Level II.

Correction of a Hyperflexed Hallux in a Saker Falcon (Falco cherrug) by Hemisectioning the Deep Digital Flexor Tendon

A 3-year-old male saker falcon (Falco cherrug) was presented with a history of hyperflexion of the first digit of the left pelvic limb with what appeared to be a hypercontracted distal end of the deep digital flexor tendon (m. flexor hallucis longus). Conservative treatment, bandaging, and splinting techniques failed to resolve the hypercontraction of the deep digital flexor tendon and improve digit function. Intraoperatively, the deep digital flexor tendon was found to have formed adhesions with the tendon sheath as well as the bone and soft tissue structures underneath it, impeding its ability to move freely within the tendon sheath. The adhesions were surgically resolved, and the tendon was lengthened by hemisectioning the deep digital flexor tendon at its distal end. Postsurgically, the digit was maintained in an extended position by bandaging. Mild physiotherapy was provided at 5-day intervals to retain function and prevent adhesions. Digit extensibility and function were restored to nearly normal levels after 4 weeks.

Subungual Glomus Tumor of the Hallux A Report of 4 Cases

This study reports the clinical outcomes and evolution of 4 patients with subungual glomus tumor (GT) of the hallux treated with tumor excision. Preoperatively, all patients had pain of intensity 9 or 10. Three were sensitive to cold and had stabbing pain, and one reported pulsatile pain. No patient presented nail alterations. There were no bone alterations on radiographic images and diagnostic suspicion of GT was supported by magnetic resonance images. Surgical treatment was indicated due to severe pain and functional limitation. The GT excision was performed by removing the nail through an L-shaped incision in the nail bed. After surgery, they all showed clinical improvement with return to previous activities and had no difficulty in wearing regular shoes. Three patients were pain-free and one had occasional stabbing pain of intensity 2. Half of them had nail changes. There has been no recurrence so far. Thus, we found that resection of subungual GT of the hallux was effective for the clinical improvement of patients.Level of Evidence: IV, case reports.

Dorsal Dislocation of the First and Second Metatarsophalangeal Joint: A Case Report and Literature Review

Dorsal dislocation of the toes is an infrequent injury that can result in severe pain and deformity. Timely diagnosis and appropriate management are paramount for optimizing patient outcomes. This case report illustrates a 53-year-old male patient who suffered dorsal dislocation of the first and second metatarsophalangeal (MTP) joints due to a crush injury. We present the clinical manifestation, radiographic findings, and management approach for this unique isolated first and second ray MTP joint dorsal dislocation, without any associated fractures. This case report underscores several critical observations: firstly, hallux dorsal dislocation can potentially coincide with other injuries; secondly, it can stem from crushing trauma to the big toe; and thirdly, successful closed reduction, when followed by effective immobilization and early rehabilitation, can yield outstanding outcomes. Additionally, the report emphasizes the importance of pursuing another closed reduction attempt under general anesthesia, if the initial attempt in the emergency room proves unsuccessful, before contemplating open reduction.

Development and Earliest Validation of a Portable Device for Quantification of Hallux Extension Strength (QuHalEx)

Hallux strength is associated with sports performance and balance across the lifespan, and independently predicts falls in older adults. In rehabilitation, Medical Research Council (MRC) Manual Muscle Testing (MMT) is the clinical standard for hallux strength assessment, but subtle weakness and longitudinal changes in strength may go undetected. To address the need for research-grade yet clinically feasible options, we designed a new load cell device and testing protocol to Quantify Hallux Extension strength (QuHalEx). We aim to describe the device, protocol and initial validation. In benchtop testing, we used eight precision weights to apply known loads from 9.81 to 78.5 N. In healthy adults, we performed three maximal isometric tests for hallux extension and flexion on the right and left sides. We calculated the Intraclass Correlation Coefficient (ICC) with 95% confidence interval and descriptively compared our isometric force-time output to published parameters. QuHalEx benchtop absolute error ranged from 0.02 to 0.41 (mean 0.14) N. Benchtop and human intrasession output was repeatable (ICC 0.90-1.00, p < 0.001). Hallux strength in our sample (n = 38, age 33.5 ± 9.6 years, 53% female, 55% white) ranged from 23.1 to 82.0 N peak extension force and 32.0 to 142.4 N peak flexion, and differences of ~10 N (15%) between toes of the same MRC grade (5) suggest that QuHalEx is able to detect subtle weakness and interlimb asymmetries that are missed by MMT. Our results support ongoing QuHalEx validation and device refinement with a longer-term goal of widespread clinical and research application.

Refractory satellite ganglion cyst in the hallux and finger

Painful ganglion cysts that develop in the hallux and finger usually enlarge progressively to the peripheral direction. Simple resection of satellite ganglion cyst alone has been reported to cause a high rate of recurrence and treatment is often very difficult. The purpose of this study is to evaluate the appropriate surgical treatment for painful satellite ganglion cysts in the hallux and finger and discuss the origin of the ganglion cysts in cases treated surgically at our hospital. We reviewed five cases (three males and two females, ages 55-87 years), three of which occurred in the hallux and two in the finger. In all cases, the preoperative magnetic resonance image showed a large fluid of the flexor tendon sheath. And also, joint effusion was found in the metatarsophalangeal joint and the proximal interphalangeal joint. The first case of the hallux ganglion underwent simple excision of the cyst and had recurrences three times. In the other four cases, the additional synovectomy of the metatarsophalangeal joint and the proximal interphalangeal joint was performed along with ganglion cyst excision. These cases had no recurrence up to 1 year after operation. Recently, there have been reports that tendon sheath ganglions are connected to the ankle, wrist, hallux, and phalangeal joints. Although there are a few cases in our department, satellite ganglion cyst of the hallux and finger possibly originates from adjacent joints. Additional synovectomy of the affected joint should be performed for the excision of satellite ganglion cyst to prevent recurrence.

Arthroscopic Repair of Chronic Plantar Plate Tears of the First Metatarsophalangeal Joint: A New Surgical Technique With Patient Outcomes

Background

Most plantar plate tears of the first metatarsophalangeal joint can be treated successfully by nonoperative means. Primary repair may be indicated to restore continuity of the plantar structures and joint stability. Inadequate or failed nonoperative treatment may cause persistent pain and disability and thereby represent a career-threatening injury to an athlete. The chronic plantar plate tears are difficult both to diagnose and to treat. When surgical treatment is indicated, traditionally a wide plantar or 2 parallel incisions are used. An arthroscopic approach allows for verification and visualization of the injury and, at the same time, repair of the injury.

Purpose

To describe findings of plantar plate tears, present a new arthroscopic procedure for plantar plate tear repair, and present the outcomes after surgery.

Study Design

Case series; Level of evidence, 4.

Methods

This was a retrospective study on the first 10 patients treated with the arthroscopic technique. The patients underwent surgery between June 2017 and January 2021. Patient data, clinical symptoms and findings, and operative details were obtained from the patient records. Patients were contacted via email to complete patient-reported outcome measures (Manchester Oxford Foot Questionnaire [MOxFQ] and Numeric Rating Scale [NRS] for pain).

Results

Four female and 6 male patients with a median age of 24 years (range, 12-44 years) were operated on at a median of 20 months (range, 2-38 months) after injury. Of the 10 patients, 8 had a hyperextension injury of the first metatarsophalangeal joint and 7 had a subtle valgus malalignment of the hallux; 8 patients were injured during sport activity. All patients reported plantar pain at pushoff. All but 1 patient returned to the same level of preinjury activity within 6 months. At a median of 29 months (range, 7-49 months) after surgery, the median MOxFQ score was 6 (range, 0-41) and the median NRS pain score was 0.

Conclusion

Arthroscopic plantar plate repair of chronic plantar plate tears resulted in a high rate of return to activity/sport and excellent outcome scores.

Radiographic Evaluation of Isolated Continuous Compression Staples for Akin Osteotomy Fixation

Continuous compression implants (nitinol staples) are gaining popularity secondary to their lower profile, less demanding technique, and less surgical dissection. Biomechanical support exists; however, clinical data is limited in the foot/ankle. This study's purpose is to determine the efficacy of nitinol staples to achieve stable, bony healing in Akin osteotomies and examine their clinical outcomes, complications, re-operations, and pain scores. We performed a retrospective chart review on 90 patients (93 osteotomies) who underwent an Akin osteotomy using a nitinol staple over a 2-year period. Radiographs were randomized and independently reviewed by 3 blinded foot and ankle surgeons. Osteotomies were deemed healed if greater than 50% of the osteotomy contained bridging bone, partially healed as less than 50% bridging bone, and nonunion as no healing, broken hardware, or loss of reduction. Visual analog scale pain scores were analyzed. Radiographic union was seen in 98.9% of Akin osteotomies (92/93), with no loss of reduction or broken staples (0/95). Only 3.2% (3/93) of patients returned to the operating room unplanned: 1 infection (1.1%), 1 symptomatic hardware removal (1.1%), and 1 traumatic disruption of fixation (1.1%). Postoperative pain scores were significantly lower than preoperative. Staples are lower profile and technically less demanding compared to headed screws, plates, and tension band constructs. They offer continuous compression of the osteotomy and are rigid enough to maintain reduction. Based on the findings of this paper, the use of staples provides robust and stable fixation for Akin osteotomies and has low complication and high healing rates.

The northern treeshrew (Scandentia: Tupaiidae: Tupaia belangeri) in the context of primate locomotor evolution: A comprehensive analysis of gait, positional, and grasping behavior

The locomotor behaviors of treeshrews are often reported as scurrying "squirrel-like" movements. As such, treeshrews have received little attention beyond passing remarks in regard to primate locomotor evolution. However, scandentians vary considerably in habitat and substrate use, thus categorizing all treeshrew locomotion based on data collected from a single species is inappropriate. This study presents data on gait characteristics, positional, and grasping behavior of the northern treeshrew (Tupaia belangeri) and compares these findings to the fat-tailed dwarf lemur (Cheirogaleus medius) to assess the role of treeshrews as a model for understanding the origins of primate locomotor and grasping evolution. We found that northern treeshrews were primarily arboreal and shared their activities between quadrupedalism, climbing and leaping in rates similar to fat-tailed dwarf lemurs. During quadrupedal locomotion, they exhibited a mixture of gait characteristics consistent with primates and other small-bodied non-primate mammals and demonstrated a hallucal grasping mode consistent with primates. These data reveal that northern treeshrews show a mosaic of primitive mammalian locomotor characteristics paired with derived primate features. Further, this study raises the possibility that many of the locomotor and grasping characteristics considered to be "uniquely" primate may ultimately be features consistent with Euarchonta.

Functional Capabilities After First Metatarsal Phalangeal Joint Arthrodesis Using a Locking Plate and Compression Screw Construct

Arthrodesis of the first metatarsal phalangeal joint (MTPJ) is a widely utilized surgical procedure for a wide array of metatarsal pathologies. This study aims to explore the functional limitations following first MTPJ arthrodesis, overall satisfaction and patient's abilities to achieve activities of daily living (ADL). This prospective cohort study assessed functional limitations as well as footwear and lifestyle restrictions using several questionnaires. One hundred and three participants who had a first MTPJ arthrodesis under the care of a single surgeon were recruited. Pre- and postoperative patient-reported outcome measures were recorded. The American Orthopaedic Foot and Ankle Score (AOFAS) and the Manchester-Oxford Foot Questionnaire were also used to further examine functional status. Hallux valgus angle (HVA) and intermetatarsal angle (IMA) were compared using preoperative and postoperative weightbearing radiographs and successful fusion was recorded. Complications were documented and are discussed in detail. The duration of follow-up was more than 12 months. There was one nonunion in the cohort while 2 patients experienced delay to fusion. Approximately 97% of patients were very satisfied with the procedure and their ability to achieve ADLs post operatively. A further 82.5% of patients were able to return to wearing nonadaptive footwear. The mean reduction in HVA and IMA was 21.78° and 6.84°, respectively. This study demonstrates the safe and successful use of a compression screw/locking plate construct for arthrodesis of the first MTPJ. Furthermore, the study provides clear evidence of high levels of functionality after the procedure with statistically significant differences (p value <.05) in all 4 facets of the AOFAS questionnaire as well as several notable differences in activity levels and footwear restrictions pre and postoperatively.

Prototype Development of a Combined Padded Metatarsal Cup for High Heeled Footwear to Enhance Female Foot Musculoskeletal Safety

This study investigated the feasibility of combined padded metatarsal cup on plantar pressures and stress distribution in the bone alignment of female foot with high heeled footwear during balanced standing. The aim of this study is to redistribute the plantar pressure away from the medial side of the forefoot. A combined padded metatarsal cup (CPMC) was developed from medium soft ethylene vinyl acetate (MSEVA) and very soft ethylene propylene diene monomer (VSEPDM) neoprene sponge. The participants of three categories were selected for the study. The peak plantar pressure and a radiographic assessment of foot musculoskeletal alignment were carried out. The results showed that the magnitude of load on medial forefoot area could be effectively reduced by inserting joint of soft materials on metatarsal region. Hence load on hallux could also be reduced satisfactorily which could resist the hallux valgus deformity. A comparison of conventional system and jointing materials separately with the developed prototype was made and found that the developed prototype of CPMC provides more relaxation of plantar pressure and musculoskeletal safety and confirms more comfort on hypothesis test. The concept of combined padded metatarsal cup should therefore be considered to help in designing musculoskeletal safety footwear.

Symmetry of bilateral hallux valgus deformity: A radiographic study

Hallux valgus (HV) is a common anatomical deformity leading to pain and difficulty with footwear and mobility. Bilateral HV deformity is much more common than unilateral although it remains unclear whether the severity of deformity is equal between feet. The objective was to investigate the severity and symmetry of HV in patients with bilateral symptomatic deformity presenting for surgery. Weight-bearing radiographs of patients presenting with symptomatic bilateral HV were reviewed. The hallux valgus angle (HVA) and intermetatarsal angle (IMA) were measured and classified as mild, moderate, or severe. Left-to-right comparison was undertaken to assess whether the degree of deformity was similar for each foot. The relationship between age, HVA, and IMA was also assessed. Between July 2014 and June 2020, 322 ft (161 patients with bilateral deformity) underwent corrective HV surgery. Of those, 6.8%, 64.6%, and 28.4% were classified as mild, moderate, and severe, respectively on the left side, and on the right 6.2%, 67.7%, and 26.1% were classified as mild, moderate, and severe respectively. There was no statistically significant difference between feet for either IMA (p = 0.06) or HVA (p = 0.85). There was a moderate correlation (R = 0.41, p ≤ 0.001) between HVA and IMA. There was only a 'weak' or 'very weak' correlation between age and HVA or IMA. Patients presenting for surgery with symptomatic bilateral HV have symmetrical moderate radiographic deformity at the time they present for consideration of surgical intervention.

Allograft Interposition Bone Graft for First Metatarsal Phalangeal Arthrodesis: Salvage After Bone Loss and Shortening of the First Ray

BACKGROUND

Previous studies have demonstrated success in using autogenous bone graft for arthrodesis in patients with failed surgeries of the hallux. These patients have several causes for pain and dysfunction preoperatively, including a shortened first ray, nonunion, and poor hallux alignment.

METHODS

In this study, a consecutive series of 36 patients (38 procedures) were treated with a patellar wedge interposition structural allograft to salvage bone loss from great toe arthrodesis malunion, painful joint replacement, failed osteotomy, or infection of the great toe metatarsophalangeal (MP) joint with shortening of the first ray. The goals of the surgery were to restore length to the first ray and provide a stable MP joint fusion to relieve pain. The 38 treated toes were evaluated for preoperative and postoperative American Orthopaedic Foot & Ankle Society (AOFAS) MP scores, subjective patient outcome scores, and clinically successful fusion of the hallux.

RESULTS

At a minimum 1-year follow-up (mean, 3.2 years), all but 2 feet healed with a solid fusion, and all healed patients reported good or excellent outcomes. AOFAS MP scores averaged 43.5 preoperatively and 77.2 postoperatively. Three patients with infection as cause for nonunion of the initial procedure were treated with staged procedures, including the use of a temporary antibiotic spacer and mini external fixator; all 3 healed without recurrent infection. One patient had a fracture of her allograft following her interposition arthrodesis, but it fused successfully after a second interposition arthrodesis surgery. Two patients developed a nonunion of the revision arthrodesis.

CONCLUSION

The use of an interposition patellar wedge allograft can restore length to the first ray and provide successful salvage of arthrodesis nonunions and bone loss from failed hemiarthroplasty and total joint implants of the great toe MP joint.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Effectiveness of the Lapidus plate system in foot surgery: A PRISMA compliant systematic review

Lapidus arthrodesis is an established standard procedure to correct various foot surgery problems and hallux limitus, hypermobility of the first ray, hallux abductus valgus, and symptomatic lesser metatarsal. After decades, many fixation methods in the orthopaedic surgery industry have been developed for decreasing complications and improving this technique. The aim of this PRISMA compliant systematic review is to analyse the effectiveness of several lapidus plate systems in foot surgery. We have carried out the first systematic review of the relevant published literature so as to systematically evaluate the scientific knowledge available now on this association, assigning predefined eligibility criteria. Fourteen studies were selected which had an overall of 738 cases. The first tarsal metatarsal joint and hallux valgus were treated by the application of different types of Lapidus plate system. The optimal level of the fixation in these procedures is related with the type and system insertion place of the plate with or without screw in each specific foot disease. There is an insufficient number of studies about the effectiveness of the different types of Lapidus plate system in foot surgery, and there is a need to increase outcomes knowledge on the level of the fixation, sort of the system, and insert place in foot surgery.

Fibular Strut Arthrodesis for Salvage of Campanacci Grade III Giant Cell Tumor of the Hallucal Proximal Phalanx: A Case Report

Involvement of toe phalanges by giant cell tumor (GCT) is extremely rare; tumors in these locations tend to be aggressive. Whereas aggressive GCTs of the distal phalanx may be managed successfully by en-bloc resection without reconstruction or amputation, management of these lesions, when they involve the proximal phalanx, can be challenging. We present a Campannaci grade III GCT of the hallucal proximal phalanx in a 14-year old girl that had breached into the dorsal soft tissues and the metatarso-phalangeal joint. Wide local resection of the proximal phalanx along with reconstruction arthrodesis with an autologous, non-vascularized fibular strut graft was performed. There was no recurrence at 3 years of follow-up. The patient had an excellent functional outcome. To the best of our knowledge, this is the first case reporting the outcomes of fibular strut arthrodesis for salvage of GCT of the hallucal proximal phalanx.

[Inveterate dislocation of the first metatarsophalangeal joint]

Injuries in the metatarsophalangeal joint complex of the hallux are seen with greater frequency in athletes, their importance lies in the functional limitation it generates. Early diagnosis and treatment can reduce the sequelae, however, the recognition of chronic lesions and with it the implementation of adequate therapeutic management generate improvements in quality of life. This document records a case of inveterate dislocation of the metatarsophalangeal joint of the hallux of more than one year of evolution with involvement of the intersesamoid ligament which was corrected with arthrodesis achieving immediate satisfactory results, in the medium and long term with the subsequent functional recovery and total reduction of pain.

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.

A Global Bibliometric Analysis of Hallux Valgus Research (1999-2019)

Hallux valgus (HV) is a very common deformity among foot disorders, therefore attracting strong interest from foot and ankle surgeons. We investigated publication trends on HV in the literature. The analysis was conducted through an electronic search of the Web of Science database for publications between 1999 and 2019, studying the data of origin through bibliometrics. The following search string was utilized: TI = (hallux valgus* OR hallux abductovalgus*) with filters for the English language and documents in article format. The "Bibliometrix" package of R software was used for the bibliometric analysis, and the VOSviewer was used to create graphs. A total of 789 articles were found in the electronic search, with 2,723 cited articles. The most common Web of Science category was Orthopedics (83.0%), and Coughlin M.J. was the main researcher in this field with the largest number of publications (17). The United States led in terms of the number of published articles (26.7%). An increase in the number of publications over time was noted, with 2016 being the year with the highest number of articles (78). The journal with the most articles was Foot and Ankle International, with 35.2% of the publications. The number of published studies on HV has increased rapidly since 2012. The United States ranks first in related research worldwide. The journal with the most articles was Foot and Ankle International.