Long term follow up on treatment of hallux sesamoid fracture with temporary first metatarsal joint internal fixation

Fracture of the hallucial sesamoids is a pathology that causes difficulty for surgeons and patients. Because of the low incidence and the fact that up to 64-90 % heal with non-operative management, there is a lack of clear guidance in the literature for the surgical treatment of sesamoid fracture in cases of failure of non-operative management. Here long term follow up of an alternative method of surgical treatment of sesamoid fracture recalcitrant to nonoperative management is presented. 32 individuals were treated with temporary surgical immobilisation of the 1st metatarsophalangeal joint using either crossed wires or two orthogonally placed two hole plates. The patients then underwent removal of the construct at 8 weeks post op after confirmation of healing on a CT scan. There was a 94 % union rate. Return to work was 61 days (15-90) return to sport 80 days (64-112) with no immediate complications and no recurrence. At last follow up mean 10 years (4-16) only 2 patients had gone on to asymptomatic non-union and one patient developed arthritis between the sesamoid and the metatarsal head. No patient has required further surgical intervention. This retrospective cohort of patients demonstrate that this method of treatment is a valuable option in the management of sesamoid fracture which does not alter the biomechanics of the foot and has none of the long term complications of sesamoidectomy or partial sesamoidectomy.

A rare mass with atypical localization: Heterotopic ossification associated with flexor hallucis longus

Heterotopic ossification (HO), characterized by the formation of ectopic bone, is a benign mass observed in soft tissues. Depending on its location, it can cause symptoms beyond compression, such as mechanical blockage when associated with joints, leading to limitations in joint movements. In the majority of cases, involvement of the hip and elbow joints is common, while HO can sometimes be observed in atypical locations. Trauma, head injury, and spinal cord injuries are well-recognized risk factors for HO development. However, on rare occasions, in non-traumatic cases are identified without any known risk factors. Herein, we present a rare non-traumatic HO case associated with the flexor hallucis longus (FHL) tendon in a 58-year-old female patient. She complained of pain under the first toe of her right foot while wearing shoes for a year, and a mass was detected on the plantar surface of the foot along with limitation of movement in the first metatarsophalangeal joint. Further examinations revealed that the identified mass was a mature HO lesion. Surgical treatment was performed, and during one-year follow-up, the pain subsided, and joint movements returned to normal, resulting in a satisfactory outcome. In conclusion, although many cases of HO are associated with traumatic injuries, it can sometimes be idiopathic, as in our case, and rarely it is accompanied tendon such as FHL in the foot.

Turf Toe Injury: A Pictorial Review and a Didactic Case Report

Hyperextension of the first metatarsophalangeal joint can lead to a turf toe injury of the plantar plate complex, resulting in significant morbidity for athletes. This article reviews the anatomy, pathophysiology, classification, and imaging findings of turf toe injuries. In turf toe trauma, many different structures can be injured, with the sesamoid-phalangeal ligaments the most common. Diagnosis, classification, and treatment options rely on clinical evaluation and specific magnetic resonance imaging findings. It is vital for radiologists to understand the anatomy, pathophysiology, and imaging findings of turf toe injuries to ensure an accurate diagnosis and appropriate management.

First Metatarsal Headphones-Like Lesion: A Case of Unreducible Sesamoid Complex Dislocation

CASE

A 34-year-old woman sustained a direct trauma to the left hallux during a fall. Radiographs showed a dorsal dislocation of the first metatarsophalangeal joint and a wide separation of sesamoid complex. Closed reduction was tried: postreduction radiographs displayed reduction of first metatarsophalangeal joint and a complete sesamoid complex dislocation. The patient was scheduled for surgery. Through a medial approach, open reduction together with plantar structures release and repair were performed. Functional and radiographic outcomes were satisfactory at the last follow-up.

CONCLUSION

In case of a "headphones-like lesion" surgery is required, together with plantar structures repair.

Paediatric sand toe: radiographic, ultrasound and MRI findings of dorsomedial capsular injury

Hyperflexion injury to the metatarsophalangeal joint of the great toe, referred to as sand toe, can cause significant functional impairment. To our knowledge, there have been no radiological descriptions of this injury in the paediatric age group. Here, we report radiographic, sonographic and MRI findings in a male paediatric patient who sustained a sand toe injury, highlighting structural damage to the dorsomedial capsule and medial sagittal band, and discuss sand toe's favourable prognosis with conservative management.

Grade III Turf Toe Injury in a Cowboy

Turf toe injuries are common, particularly in athletes competing on artificial turf. This debilitating injury and its associated sequelae can affect the long-term performance of athletes and others. In this case is presented an atypical cause for development of grade III turf toe. This case presents an acute injury with significant damage to the plantar first metatarsophalangeal joint, with plantar plate rupture and tibial sesamoid retraction secondary to injury involving working calves on a ranch. The anatomy, mechanism, and associated treatments are reviewed. The anatomical and functional interplay with this injury is discussed.

First Metatarsophalangeal Joint Pain in Athletes: Diagnosis, Management, and Return to Play Considerations

ABSTRACT

The first metatarsal-phalangeal joint plays a key role for athletes of various disciplines. When an athlete presents for evaluation of pain at this joint, there are several causes that should be considered. The purpose of this article is to review common injuries including turf toe, sand toe, extensor and flexor hallucis longus tendinopathy, sesamoiditis, and metatarsalgia and provide current evidence-based recommendations for diagnosis, management, and return to play considerations. Conditions not specific to athletes like gout and hallux rigidus also are discussed. Mechanism of injury, physical examination, and imaging such as weight-bearing radiographs and point-of-care ultrasound can help with diagnosis. Treatment of many of these injuries begins with nonsurgical management strategies including footwear or activity modification, physical therapy, and select interventions.

Results of a shuttle catheter technique for surgical repair of acute extensor hallucis longus tears

Background and study aims

The proximal end of a torn Extensor hallucis longus (EHL) is usually so retracted that a proximal wound extension is always required to retrieve it; leading to more adhesions and stiffness. This study aims at assessment of a novel technique for proximal stump retrieval and repair of acute EHL injuries with no need for wound extension.

Material and methods

Thirteen patients with acute EHL tendon injuries at zones III, IV were prospectively included in our series. Patients with underlining bony injuries, chronic tendon injuries and previous nearby skin lesions were excluded. Dual Incision Shuttle Catheter (DISC) technique was applied with subsequent evaluation by the American Orthopedic Foot and Ankle Society (AOFAS) hallux scale, Lipscomb and Kelly score, range of motion and muscle power.

Results

Dorsiflexion at the metatarsophalangeal (MTP) joint significantly improved from a mean of 38.4±6.2º at one month to 58±9.6º at three months to 78.8±3.1º at one year postoperatively (P=0.0004). Plantar flexion at MTP joint significantly inclined from 16±3.8º at 3 months to 30.6±7.8º at the last follow-up (P=0.006). The big toe dorsiflexion power surged from 6.1±0.9N to 11.1±2.5N to 19.7±3.4N at 1 month, 3 months and one-year follow-up periods respectively (P=0.013). As per the AOFAS hallux scale, pain score was 40 of 40 points. The mean functional capability score was 43.7 out of 45 points. On Lipscomb and Kelly scale, all were graded "good" except for one patient who was graded "fair".

Conclusion

Dual Incision Shuttle Catheter (DISC) technique represents a reliable method for repair of acute EHL injury at zones III, IV.

Alternative treatment for varus instability of the hallux interphalangeal joint: A case report

Forefoot injuries are commonly caused by sport-related activities and are often around the metatarsophalangeal joints. The hallux interphalangeal (IP) joint is anatomically stable; therefore, injuries to this joint are considered to be rare compared with those to the metatarsophalangeal joint. Instability of the hallux IP joint has rarely been reported in barefoot contact sports, and its treatment has not been sufficiently explored.This study investigated chronic varus instability of the hallux IP joint. We performed a surgical reconstruction owing to conservative treatment failure. A good surgical outcome was achieved by reconstruction of the collateral ligament using the 4th extensor tendon-a promising alternative treatment option for this type of injury. This method indicated no morbidity outside the site of surgery and was more cost-effective than reconstruction using an allograft.

A Viable Osteochondral Allograft for Articular Cartilage Replacement of the First Metatarsal Head — A Case Series

Few reports in the literature have described the use of an osteochondral allograft for the treatment of articular cartilage damage of the 1st metatarsal phalangeal joint. We present here the clinical outcomes and detailed surgical technique of four cases in which we used a cryopreserved, viable, osteochondral allograft (CVOCA) for full cartilage replacement of the first metatarsal head to address degenerative articular cartilage damage. At 10-22 months of follow-up, patients reported clinical improvement, with VAS pain-scale scores decreasing from an average of 8.0 to 0 post-operatively, and range-of-motion improvement from an average of 4.3 degrees to 58.3 degrees dorsiflexion. Radiographic improvement was also seen, with an increase in average joint space from 1.1mm, 1.5mm, and 2.2mm from medial to lateral on dorsoplantar views pre-operatively, to 3.1mm, 2.8mm, and 3.1mm 15 months post-operatively, respectively. These results suggest that CVOCA is a desirable treatment option for end-stage degenerative joint disease of the first metatarsal phalangeal joint.

The Stener Lesion: Historical Perspective and Evolution of Diagnostic Criteria

BACKGROUND

In 1962, Bertil Stener first described the anatomy and treatment of the displaced ulnar collateral ligament of the metacarpophalangeal joint, later called the Stener lesion. Since Stener's publication, treatment algorithms for ulnar collateral ligament rupture have aided in preoperative diagnosis, yet the best diagnostic method to assess ligament displacement remains largely undefined.

METHODS

An extensive literature search was performed to explore the treatment evolution of the Stener lesion and explore how technical development has influenced Stener lesion diagnosis. We also sought to illuminate the life and work of Bertil Stener.

RESULTS

Studies evaluating the use of magnetic resonance imaging (MRI) and ultrasound (US) technology have suggested that these modalities have improved Stener lesion diagnosis.

CONCLUSION

Despite the utility of developing MRI and US technology, consensus for one superior diagnostic tool for Stener lesions does not currently exist.

[Treatment of the injury of the plantar plate on the second metatarsophalangeal joint with dorsal approach and Weil osteotomy]

OBJECTIVE

To evaluate the clinical results of dorsal approach and Weil osteotomy in treating the injury of the plantar plate in second metatarsophalangeal joint.

METHODS

Eight feet with plantar plate tear in five cases were treated by plantar plate repairment through dorsal approach and Weil osteotomy from June 2012 to December 2013. The mean age of the patients was 52 years old. All the patients were followed up for 6 to 12 months. American Orthopaedic Foot and Ankle Society (AOFAS) and visual analogue scale (VAS) were used to evaluate the clinical effect.

RESULTS

The second metatarsophalangeal joint stability recovered and the pain released in all patients. Postoperative VAS was lower and AOFAS was higher than preoperative.

CONCLUSION

Combined dorsal approach and Weil osteotomy can effectively release the pian of plantar plate, stabilize the metatarsophalangeal joint, decrease the incidence rate of postoperative subluxation and anchylosis in treating plantar plate tears in the second metatarsophalangeal joint.

A variant neglected Type IIIA dorsal dislocation of first metatarsophalangeal joint. A case report

We present a rare injury consisting of a neglected, irreducible, dislocation of the first metatarsophalangeal joint that was diagnosed 4 months after the injury. An open reduction was necessary from the beginning. Patient returned to full activity without pain or disability, so a good prognosis despite the delayed diagnosis was achieved. We are unaware of previous reports in the literature describing this unusual variant.

Classification of metatarsophalangeal joint plantar plate injuries: history and physical examination variables

Although metatarsophalangeal (MTP) plantar plate tears are common, they are still often missed. The purpose of this study is to find the best clinical variables to define and grade the plantar plate injuries. Sixty-eight patients (100 MTP joints) were graded arthroscopically and divided into five groups (0 to IV) according to the anatomical classification. Their medical records were reviewed to establish correlations of clinical findings with the anatomical lesions. The positive correlations found were acute pain, widening of the interdigital space, loss of ground touch, positivity of the MTP joint drawer test, reduction of the toe purchase, and toe supination. The drawer test is the most reliable and accurate tool to classify and grade the plantar plate lesion, followed by ground touch and rotational deformities. It is possible to improve the accuracy of diagnosis of plantar plate tears by means of the combination of both clinical history and physical examination data.

[Surgical repair of chronic tears of the second plantar plate]

OBJECTIVE

To explore the operative methods and the short-term effectiveness to repair chronic tears of the 2nd plantar plate.

METHODS

Between June 2012 and June 2013, 14 patients with chronic tears of the 2nd plantar plate were treated. There were 4 males and 10 females with an average age of 65.9 years (range, 51-82 years) and with an average disease duration of 6.2 years (range, 5-9 years). The left side was involved in 5 cases and the right side in 9 cases. One patient had simple hammer toe; 2 patients had hallux valgus and claw toe; and 11 patients had hallux valgus and hammer toes. All of them had unstable the 2nd metatarsophalangeal joints. The results of modified Lachman test and drawer test were positive. The surgical treatment included a Weil osteotomy and plantar plate repair operation for rupture via dorsal incision after correcting hallux valgus.

RESULTS

Primary healing of incision was obtained in all patients. Twelve patients were followed up 6-12 months (mean, 8.2 months). Hallux valgus, claw toe, and hammer toe were all corrected. The results of modified Lachman test and drawer test were negative at 3 months after operation. Mild pain of the 2nd metatarsophalangeal joint occurred, but no stiff was observed in 2 cases at 6 months after operation. The midfoot and forefoot score of American Orthopedic Foot and Ankle Society (AOFAS) was 90.50 +/- 3.73 at last follow-up, which was significantly higher (t=21.724, P=0.000) than preoperative score (57.33 +/- 4.99).

CONCLUSION

The plantar plate is the key to maintain the stability of the metatarsophalangeal joints, and surgical repair can achieve good short-term effectiveness in treating chronic tears of the 2nd plantar plate.

[Dislocation and necrosis of the first, second and third wedges. Management with the Masquelet technique. A case report]

The induced membrane technique was first described by Masquelet in 1986. It was initially used for the reconstruction of long bone shaft defects, particularly of the femur and tibia. The technique consists of two stages. During the first stage a membrane is induced to provide support to the grafts and supply growth factors that contribute to provide a favorable receiving bed for the future graft. During the second stage the poly-methyl-methacrylate spacer is removed and replaced with bone grafts, usually harvested from the iliac crest. Given that this technique has proven good results, it started to be used at other bone sites. We present herein the case of a patient with a large bone defect in the midfoot in whom the Masquelet technique was used with iliac crest grafts. Arthrodesis with a distal radius plate was performed to improve medial column stability, with favorable clinical and functional results.

Pull-out technique for plantar plate repair of the metatarsophalangeal joint

Plantar plate rupture is a common cause of forefoot pain, multiplanar malalignment, subluxation, or dislocation of the metatarsophalangeal joint (MTPJ). The treatments that have been described for MTPJ instability of lesser toes include amputation, lengthening and/or tendon transfer, periarticular soft-tissue release (capsule, collateral ligaments, and plantar plate), colateral ligament reconstruction, metatarsal shortening osteotomy, and suture of plantar plate lesion. This article outlines the anatomy, pathogenesis, and diagnosis of plantar plate rupture, and describes a new technique that combines joint decompression by Weil osteotomy with a plantar plate repair using a pull-out technique.

Etiology and biomechanics of first metatarsophalangeal joint sprains (turf toe) in athletes

Sprains of the first metatarsophalangeal (MTP) joint, referred to colloquially as "turf toe," are a debilitating sports injury because the hallux is pivotal to an athletes' ability to accelerate and cut. Severe sprains may require weeks to full recovery, and injuries requiring surgery may prevent an athlete from full athletic participation for months. Whereas the diagnosis and treatment of turf toe are well documented in the literature, less is known about the biomechanics of this joint and the mechanical properties of the structures that compose it. Nevertheless, this information is vital to those, such as equipment designers, who attempt to develop athletic footwear and surfaces intended to reduce the likelihood of injury. To that end, this review summarizes the literature on the anatomy of the first MTP joint, on biomechanical studies of the first MTP joint, and on the incidence, mechanisms, and treatment of turf toe. Furthermore, gaps in the literature are identified and opportunities for future research are discussed. Only through a thorough synthesis of the anatomic, biomechanical, and clinical knowledge regarding first MTP joint sprains can appropriate countermeasures be designed to reduce the prevalence and severity of these injuries.

[Diagnosis and surgical treatment of tarsometatarsal joint complex injuries]

OBJECTIVE

To explore the diagnosis and surgical treatment of tarsometatarsal joint complex injuries.

METHODS

Between January 2000 and October 2009, 24 cases of tarsometatarsal joint complex injuries were treated. There were 14 males and 10 females with an average age of 38 years (range, 21-65 years). Injury was caused by a machine in 8 cases, by traffic accident in 12 cases, and by falling from height in 4 cases. All fractures were closed. The time from injury to hospitalization was 2-17 hours (5 hours on average). Open reduction and internal fixation with screw were performed.

RESULTS

Incision healed by first intention in other patients except 1 patient who had effusion at incision. Twenty-three cases were followed up 12-47 months with an average of 23 months. X-ray films showed that all fractures healed after 9-15 weeks of operation (13 weeks on average). No complication was found, such as osteofascial compartment syndrome, nonunion infection, loosening or breakage of the internal fixator. According to Maryland scoring, the results were excellent in 7 cases, good in 8 cases, fair in 5 cases, and poor in 3 cases with an excellent and good rate of 65.2%.

CONCLUSION

Anatomical reduction and stable fixation are important for satisfying results in treating tarsometatarsal joint complex injuries.

[Arthrodesis of the first metatarsophalangeal joint using a spherical reamer and titanium compression staples--preliminary report]

BACKGROUND

The role of arthrodesis of the first metatarsophalangeal joint (MTP I) for the treatment of many primary foot problems or as a salvage procedure is an well accepted procedure. In this study, authors present the results of a surgical technique using spherical reaming and compression with two titanium staples in perpendicular planes to achieve fusion. Compression across arthrodesis site is achieved by difference in width between holes in drill guide and width of titanium staple.

MATERIALS AND METHODS

27 metatarsophalangeal joint arthrodeses were performed in 24 patients with different forefoot deformities. The average age of the patients was 53 years and average followup period was 28 months.

RESULTS

The authors obtained MTP I joint fusion in 26 treated feet within 6-12 weeks. The mean AOFAS score was 49 points preoperatively and increased to 76 points at last followup.

CONCLUSION

Arthrodesis of the first metatarsophalangeal joint with spherical reaming and fixation with two titanium compression staples placed in perpendicular planes is a valuable and reproducible procedure for achieving fusion in a majority of patients.

[Arthrodesis of the lisfranc joint as salvage procedure after trauma injury]

Dislocations and fractures of the tarsometatarsal joints (Lisfranc joint) are rare, often non properly diagnosed and treated. Lack of proper diagnosis and postponed operative treatment causes painful deformity of the foot. There are presented results of operative treatment in 6 patients (6 feet) with fracture/dislocation of the Lisfranc joint. In all of them arthrodesis as salavage procedure was performed. Age at the fracture/dislocation ranged from 13 to 58 years. After trauma no one was treated operatively. Injury was overlooked in 2 patients. Indications for arthrodesis were pain causing limping as well flattening and abduction deformity fo the foot. Arthrodesis was performed from 1 to 39 years after trauma. It was closing wedge resection of the Lisfranc joint, stabilization with Kischner wires for 6 weeks and below knee plaster cast for 3 months. Follow-up ranged from 14 to 52 months. Functional results in AOFAS scale ranged from 6 do 90 points (mean 63 points) of 100. Subjective results ranged from 1 to 8 points (mean 5.6 points) of 10. Two females were not satisfied with the results of treament.

Arthroscopic diagnosis and treatment of intra-articular insertional injuries of the suspensory ligament branches in 18 horses

REASONS FOR PERFORMING STUDY

Clinical association between the branches of insertion of the suspensory ligament (SL) and metacarpophalangeal (MCP) and metatarsophalangeal (MTP) joints has been reported. However, there has been no assessment of the lengths of the SL branches which are subsynovial with respect to the joints or reports of involvement of the MCP/MTP joints in injuries of the SL branches.

OBJECTIVES

To establish proportions of SL branches subsynovial with respect to the MCP/MTP joints and report clinical and arthroscopic findings in horses with desmitis of SL branches identified as having an articular component to the lesion.

HYPOTHESIS

Arthroscopic surgery enables identification and potential treatment of intra-articular injuries of SL branches.

METHODS

Twelve forelimbs and 13 hindlimbs were dissected and the total and subsynovial lengths of the SL branches recorded. Case records of horses with intra-articular injuries of the SL branches were reviewed and 18 animals identified. Diagnostic information and arthroscopic findings were recorded and results of treatment determined by telephone follow-up.

RESULTS

Of SL branches, 28.45% in the forelimb and 29.56% in the hindlimb were subsynovial to the MCP and MTP joints. All animals with intra-articular lesions of the SL branch were lame and had distension of the affected MCP/MTP joint. In 16 horses (17/22 branches), there was palpable thickening of the affected SL branch. Disrupted infrastructure was evident ultrasonographically in 15/17 branches and involvement of the dorsal articular surface of the ligament was predicted in 12/17 branches. Following arthroscopic intervention, 13 horses returned to work at a level equal to or greater than that achieved prior to injury and 2 returned to work at a lower level. Three horses incurred separate injuries and were retired or subjected to euthanasia.

CONCLUSIONS

Articular involvement should be considered in animals with injuries of an SL branch and concurrent distension of the MCP/MTP joint. Arthroscopy is necessary to identify such lesions confidently and to direct case management.

POTENTIAL RELEVANCE

Arthroscopy of the MCP/MTP joints can make a positive contribution to the assessment and management of some SL branch injuries.