MP I joint giving way--a case study

A case history of a 26 year old international class female 400 m hurdle sprinter is presented. While sprinting she felt a sudden and very intensive pain at her left hallux. After this she was unable to run and had episodes of giving way in the MP I joint elicited by minor activity. Operative investigation revealed a broad disruption of the MP I medial collateral ligament. After periosteal flap repair and early functional aftertreatment she returned to full high level sports ability.

Injuries to the toes and metatarsals

Traumatic injuries to the toes and metatarsals are common injuries affecting nearly every individual. Injuries may be precipitated by industrial accidents or simple bumps in the night. They can produce a wide spectrum of consequences ranging from permanent disability to asymptomatic deformities. With appropriate treatment, most individuals should have the capacity to return to their preinjury functional status.

Periarticular injuries to the hallux metatarsophalangeal joint in athletes

The magnitude of hallux MTP injuries can range from a mild sprain to a frank dislocation. The importance of coaches, trainers, and physicians recognizing the severity of a turf toe injury cannot be overstated. The late sequelae of hyperextension injuries can lead to retirement from professional athletics. With appropriate conservative treatment, most individuals can return to play, although many have some residual pain. Future study in this area should define the indications for acute repair versus late treatment following a period of conservative modalities. Hyper-plantarflexion injuries also can be debilitating injuries, but most respond to rest, taping, anti-inflammatories, ice, and strengthening exercises. Lastly, dislocations of the hallux MTP joint can be diagnosed and treated after physical examination and appropriate radiographs are obtained. All closed dislocations should undergo an attempt at reduction in the emergency department after adequate anesthesia is administered. The patient should be advised, especially in type I injuries, of the need for possible acute operative intervention.

Traumatic hallux varus repair utilizing a soft-tissue anchor: a case report

Hallux varus is usually iatrogenic in nature; however, congenital and acquired etiologies have been described in the literature. The authors present a case of traumatic hallux varus secondary to rupture of the adductor tendon. Surgical correction was performed using a soft tissue anchor for maintenance of the soft tissues utilized for repair.

[Gauthier's subcapital osteotomy in the treatment of metatarsophalangeal luxation of the 2nd ray. Apropos of 44 cases with 5 year followup]

The authors report on a series of 44 metatarsophalangeal dislocations of the second ray which were treated surgically using Gauthier's technique. The patients were 44 middle-aged women. The surgical indication was a dislocation of the 2nd metatarsophalangeal joint with hallux valgus. There was excess length of the second metatarsal ray or acquired shortness of the first metatarsal. The treatment always included an osteotomy of the neck maintained by a transosseous pin. The average follow-up was 8 years and 3 months (minimum 5 years). Postoperative results were evaluated using clinical and radiological criteria. Surgical treatment gave 68.2% very good and good results and 4 recurrences of dislocation. The results in this series are identical with those in other series reported, but the backward displacement of the head of second metatarsal was found to be limited. Weil's osteotomy seems to provide better results because it better restores the relative lengths of the metatarsals and often makes interphalangeal arthroplasty unnecessary. Gauthier's metatarsal osteotomy is an easy procedure which effectively improves static metatarsalgia, but it provides limited metatarsal shortening. Weil's osteotomy is preferable in cases with long lateral metatarsals.

[Short-term outcome of Weil osteotomy in treatment of metatarsalgia]

INTRODUCTION

The aim of this retrospective study was to analyse the short term results after the Weil-procedure for the treatment for metatarsalgia in 30 consecutive patients.

METHODS

30 patients (69 osteotomies) after the Weil-procedure with an average age of 60 years (range 25 to 78 years) were analysed by clinical and radiological evaluation. The average follow up was 15 months (range 12 to 26 months). Analysis was performed using the patients' records, weight-bearing radiographs and a standardized questionnaire.

RESULTS

Subjective evaluation revealed 23 very satisfied and satisfied patients. Based on the Lesser-Metatarsal-Interphalangeal-Scale the objective results showed 77.1 points on average. The results were excellent in 17 cases, good in 4, fair in 3 and unsatisfactory in 6 cases respectively. Recurrent metatarsalgia was noted in 5 cases, whereas no transfermetatarsalgia was observed. The average shortening was 4.4 mm. Subluxation of the metatarsophalangeal joint was corrected in 18 out of 22 cases. A restricted plantar flexion of the metatarsophalangeal joint was noted in 14 cases. 2 patients showed loss of movement.

CONCLUSION

Our short-term results reveal that the Weil-osteotomy is a sufficient treatment for metatarsalgia. This technique is able to reestablish the alignment of the metatarsals and to correct luxation and subluxation of the metatarsophalangeal joint. Restricted plantarflexion of the metatarsophalangeal joint is a drawback, which may be avoided by intensive physiotherapy.

Arthroscopy of the first metatarsophalangeal joint

We carried out 12 arthroscopies of the first metatarsophalangeal (MTP) joint in 11 patients over a five-year period. Their mean age was 30 years (15 to 58) and the mean duration of symptoms before surgery was eight months (1 to 24). Six patients had an injury to the joint; all had swelling and tenderness with a reduced range of movement. In six patients, radiographs revealed no abnormality. Under general anaesthesia with a tourniquet the hallux is suspended by a large Chinese finger trap to distract the joint. Using a 1.9 mm 30 degree oblique arthroscope the MTP joint is inspected through dorsomedial and dorsolateral portals with a medial portal if necessary. All patients were found to have intra-articular pathology, which was treated using small instruments. The mean follow-up was 19.3 months (6 to 62) and all patients had no or minimal pain, decreased swelling and an increased range of movement of the affected joint.

Dislocation of the first metatarsophalangeal joint with fracture of fibular sesamoid. A case report

Dorsal dislocations of the first metatarsophalangeal joint are classified by Jahss into two types. In Type 1, the hallux with the intact intersesamoid ligament dislocates dorsally over the metatarsal head. Such cases in the literature have been irreducible by closed manipulation. In Type 2 the hallux is dislocated dorsally with rupture of the intersesamoid ligament, resulting in wide separation of the sesamoids (Type 2A) or a transverse fracture of one or both sesamoids (Type 2B). The importance in classifying these injuries allows one to predict whether closed reduction will be successful as in Type 2. The patient reported had a fracture of the fibular sesamoid in addition to dislocation of the hallux. The clinical findings were consistent with Type 1 injury, including an intact intersesamoid ligament, but the radiographs showed, in addition to the dislocation, that there was a fracture of the fibular sesamoid. Reduction was achieved surgically through a dorsal approach. Although such injuries have been unreported previously, Type 1 injuries may be associated with a fracture of the fibular sesamoid but without rupture of intersesamoid ligament, so the injury reported is classified as Type 1A.

Comparison of the results of the Weil and Helal osteotomies for the treatment of metatarsalgia secondary to dislocation of the lesser metatarsophalangeal joints

We retrospectively reviewed the outcome of 30 patients who were treated surgically for metatarsalgia resulting from dislocation of one or more lesser metatarsophalangeal (MTP) joints. We used two treatments, including an osteotomy of the metatarsal head (Weil osteotomy, N = 15) or an osteotomy of the metatarsal shaft (Helal osteotomy, N = 15). Before surgery, all patients had been treated with various nonoperative modalities for a minimum of 6 months. Between 1991 and 1993, 15 consecutive patients underwent a Helal osteotomy (22 metatarsals), and 15 consecutive patients were subsequently treated between 1994 and 1995 with a Weil osteotomy (25 metatarsals). All patients were evaluated clinically and radiographically at a mean follow-up period of 22 months (range, 12-39 months), noting especially persistent subluxation or dislocation, recurrent metatarsalgia, and transfer lesions. Patients managed with a Weil osteotomy had significantly higher satisfaction (P = 0.049), lower incidence of recurrent metatarsalgia (0 vs. 27%, P = 0.107), and fewer transfer lesions (0 vs. 41%, P = < 0.001) than those managed with a Helal osteotomy. Furthermore, those managed with the Weil procedure had a higher percentage of radiographic reduction and maintenance of the MTP joint dislocation (21 of 25, 84%; vs. 8 of 22, 36%; P = 0.002) than those managed with the Helal procedure. In the Weil group, there was also no malunion or pseudoarthrosis; in the Helal group there were five malunions and three pseudoarthroses. Although the follow-up period for the Weil osteotomy (15 months) was shorter than that for the Helal osteotomy (26 months), the former group had higher American Orthopaedic Foot and Ankle Society forefoot scores, which were significantly different from the results attained with the Helal osteotomy. A telephone update was performed on the Weil osteotomy group at an average of 27 months postsurgery, and no patient had experienced changes since the clinical follow-up. We concluded that the Weil procedure is a satisfactory method for correcting metatarsalgia caused by dislocation of the MTP joint and that, because of the high complication rate, the Helal osteotomy is not an acceptable procedure for correcting this condition.

[Common overuse knee-to-toes injuries in recreational exercise. Most cases are treatable in primary health care]

Although overuse injuries are common among recreational exercise-takers, in most cases they are treatable in primary care. It is important to evaluate both intrinsic and extrinsic aetiological factors underlying the development of overuse injuries. Treatment should always be focused on the aetiological factors, rather than solely on the symptoms. After an initial period of rest, a supervised rehabilitation programme, combined with correction of intrinsic and extrinsic factors, is the optimal treatment for most overuse syndromes. Surgery is only rarely necessary.

[Static instability and dislocation of the 2nd metatarsophalangeal joint. Comparative analysis of 2 different therapeutic modalities]

PURPOSE OF THE STUDY

The authors report the results of instabilities and dislocations treatment of the second metatarsophalangeal joint using two different surgical methods.

MATERIAL AND METHODS

This study included 129 patients (131 feet) with 19 instabilities, 43 subluxations and 69 dislocations of the second metatarsophalangeal joint. The first group of 66 patients (75 feet operated before 1994) had an arthrolysis using a dorsal approach associated to a lengthening of the tendon extensor digitorum longus. Reduction of the metatarsophalangeal joint was fixed by a K wire (15 feet of this group had an associated basimetatarsal osteotomy). The second group of 53 patients (56 feet operated since 1994) had the association of arthrolysis, tendon lengthening, and distal metatarsal osteotomy according to S. Weil.

RESULTS

Results were appreciated on different criterions: deformity recurrence, emergence of metatarsalgia on the adjacent ray, discomfort in walking and shoe wearing. Results are significantly better in the second group of patients.

DISCUSSION

The main cause of second ray lesions is related to metatarsal relative length abnormality. The authors compare different surgical techniques for the metatarsophalangeal joint, distally and proximally to it, and assess indications.

CONCLUSION

The better the relative length abnormality is corrected, the better is the prognosis after treatment.

Atypical medial dislocation of the first metatarsophalangeal joint

Medial dislocation of the great toe without fracture or sesamoid separation is an unusual event. We are reporting such a case which occurred in a man after a motor vehicle accident. The patient was treated with closed reduction and cast immobilization. The patient recovered all his activities after 30 days. Three-year follow-up showed a complete recovery, clinically and radiographically, with only slight radiographic signs of osteoarthritis, which was present also in the contralateral foot.

Variant of the Lisfranc fracture-dislocation: a case report and review of the literature

Lisfranc fracture-dislocations are uncommon injuries with several variations. We present one such variation and include a pertinent review of the literature. This case is unusual in that there was lateral tarsometatarsal disruption with neither diastasis between the first and second metatarsals nor injury to either the first or second tarsometatarsal joints. Destabilization of the lateral Lisfranc joints was secondary to fractures through the second and third metatarsal shafts. Anatomic reduction and stabilization of the lateral Lisfranc joints resulted only after open anatomic reduction and internal fixation of the metatarsal fractures. Two-year follow-up confirmed an excellent clinical and radiographic result.

Stabilization of the subluxed second metatarsophalangeal joint: flexor tendon transfer versus primary repair of the plantar plate

Surgical treatment of the subluxed second metatarsophalangeal joint (MTPJ) has been a consistently frustrating problem for the foot and ankle surgeon. The plantar plate is the principal stabilizing structure of the second MTPJ and compromise to its integrity has been implicated as the cause of the subluxed second toe. Flexor tendon transfer has been reported as the mainstay of treatment to stabilize the subluxed second MTPJ. Recently, primary repair of the plantar plate has been advocated, yet no research exists comparing it to flexor tendon transfer. Eight freshly frozen lower extremity cadaver specimens were mounted on a custom-fabricated load frame. A vertical dorsally directed force was applied to the base of the proximal phalanx of the second toe via a pneumatic actuator to stimulate the Lachman test. Dorsal displacements of the proximal phalanx were measured with a linear variable distance transducer. This investigation examined the comparative strength of flexor tendon transfer versus primary repair of the plantar plate in stabilizing the second MTPJ. Results showed a significant difference between the transected plantar plate and the intact plantar plate. Displacements for the repair groups were similar to the intact plantar plate group and also significantly different from the transected plantar plate. Primary repair of the plantar plate is a viable alternative to flexor tendon transfer in stabilizing the second MTPJ with the advantage of addressing the pathology anatomically. Clinical studies are needed to substantiate these laboratory findings.

Subchondral bone failure in an equine model of overload arthrosis

Gross examination of metacarpo-/metatarsophalangeal (fetlock) joints from racehorses revealed defects on the condylar surface that ranged from cartilage fibrillation and erosion to focal cartilage indentations and cavitation in subchondral bone characteristic of traumatic osteochondrosis. Because these lesions represented a spectrum of mechanically induced arthrosis in which microdamage is thought to play a role, a histologic study of sagittal sections was made to study the morphogenesis. Subchondral bone failure developed beneath a flattened section of the condyle where the margin of the sesamoid bone produces compression as well as shear on impact of the foot with the ground. Milder lesions had thickening of subchondral bone and underlying trabeculae. With advancing sclerosis an increased amount of osteocyte necrosis was present. Occasional vascular channels with plugs of matrix debris and cells were present just beneath the cartilage. There was increased prominence of subchondral vessels, and osteoclastic remodeling was seen in and around the sclerotic zone. Apparent fragmentation lines in the subchondral bone suggested increased matrix fragility. Irregular trabecular microfractures developed at a depth of a few millimeters. Increased vascularity with hemorrhage, fibrin, and fibroplasia could be seen in enlarged marrow spaces at this more advanced stage. The overlying articular cartilage was variably indented but remained largely viable with degeneration and erosion limited to the superficial layers. Focally, breaks in the calcified layer appeared to lead to collapse and cartilage infolding. In metacarpal condyles from experimental horses run on a treadmill, there were milder changes at the site. The subchondral bone was increased in volume and there was increased diffuse staining with basic fuchsin, but no increase in the number of microcracks was seen. The findings in the racehorses indicate that the equine fetlock condyle is a consistent site of overload arthrosis in which microfracture and failure in subchondral bone may occur. Controlled exercise in treadmill horses may provide a model in which to study the pathogenesis.

Rupture of the medial collateral ligament of the first metatarsophalangeal joint in a professional soccer player

Worldwide, more people play soccer than any other team sport. The Federation Internationale de Football Association (FIFA) registered more than 150 million players in 1984. Although foot injuries in soccer range from midfoot sprains to stress fractures to capsulitis of the first metatarsophalangeal joint, we could find no case reports of a rupture of the lateral collateral ligaments of the great toe in soccer players. This is a report of the diagnosis, treatment, and outcome of such an injury in a professional soccer player.

The plantar marginal septum cutaneous island flap: a new flap in forefoot reconstruction

Soft-tissue reconstruction of the foot very often requires flap coverage to preserve exposed structures such as bone, joint, tendons, and weight-bearing areas. However, forefoot coverage remains a challenge, since the alternatives for flap coverage are very limited. The vascularization of the medial side of the foot was studied in 25 injected limbs. Based on this anatomic knowledge, the plantar marginal septum cutaneous island flap is described. The plantar marginal septum cutaneous island flap is a reversed-flow flap based on the superficial branch of the medial division of the medial plantar artery and its distal anastomosis with the lateral plantar artery, first dorsal metatarsal artery, and lateral branch of the medial plantar artery. The venous drainage is ensured by the accompanying veins. The flap arc of rotation includes the forefoot plantar and dorsal region and the first and second toes. Eight cases have been operated on and are reported.

Floating metatarsal: concomitant Lisfranc fracture-dislocation and complex dislocation of the first metatarsophalangeal joint

We describe a unique composite injury of the foot, with concomitant Lisfranc fracture-dislocation, and complex dislocation of the first metatarsophalangeal joint. When examining patients with Lisfranc joint injuries, one must keep in mind that the axial compression forces causing the injury may also damage the metatarsophalangeal joints, and direct attention to these structures. The reduction and stabilization of a "floating" first metatarsal should begin at the distal (metatarsophalangeal) end. The reduction of the distal dislocation will release tension on the plantar fascia, enabling the subsequent reduction of the proximal (Lisfranc) dislocation. A medial approach is convenient, affords easy access to the plantar and dorsal aspects of the joint, and repair of the medial joint structures when damaged. The use of screws for fixation of Lisfranc's fracture-dislocation, is well justified by the stability achieved.

Dorsal dislocation of the first metatarsophalangeal joint

Traumatic dislocation of the first metatarsophalangeal joint is a rare clinical finding. Ability to reduce the dislocation by nonoperative measures depends largely on the type of dislocation and involvement of the sesamoid complex. A brief description of the incidence, anatomy, and pathomechanics of dorsal dislocation of the first metatarsophalangeal joint is given. A report of a 33-year-old female with complete dorsal dislocation of the first metatarsophalangeal joint and anatomically preserved sesamoid complex is provided.

Pathomechanics of complex dislocations of the first metatarsophalangeal joint

Because only 10 complex dislocations of the first metatarsophalangeal joint have been reported to date, a retrospective review was initiated to study the pathomechanics of 11 new cases (9 patients) and to report on the clinical and functional outcomes. Concomitant ipsilateral injuries were frequent: 6 tarsometatarsal joint partial disruptions and 8 cases with multiple midfoot or forefoot fractures or dislocations occurred. Clinical and radiographic assessments suggested that forefoot hyperextension combined with axial loading of the foot in a heel to toe or toe to heel direction produced all. Six cases required open reductions (5 were compound), and 5 cases were managed by closed methods. Associated tarsometatarsal joint disruptions facilitated closed management. The most common complaints at followup assessment (average, 7 years) were sensitive plantar wounds, partial joint ankylosis, and sesamoid sensitivity. All but 1 patient resumed the same or modified work. The data in this series suggest that most complex dislocations of the first metatarsophalangeal joint probably occur frequently with a concurrent tarsometatarsal joint sprain or disruption, and that the primary mechanism of injury is that of axial loading of the foot causing midfoot hyperflexion and forefoot hyperextension. Contrary to current opinion, not all complex dislocations of the first metatarsophalangeal joint are resistant to closed management.

Plantarflexion injury to the metatarsophalangeal joint ("sand toe")

This is a retrospective study of 12 cases of hyperplantarflexion injuries to the great toe and the lesser toes sustained in professional beach volleyball players. The hyperplantarflexion injury to the metatarsophalangeal joint, referred to as "sand toe," can result in significant functional disability. Push-off, forward drive, running, and jumping are compromised. The average player in this series took 6 months to fully recover from the injury, and the most common problem after injury was the loss of dorsiflexion, seen in six players. Five players had residual discomfort in the injured toe, and two demonstrated an unstable toe. Individuals who experience sand toe injuries should be treated conservatively, with taping, anti-inflammatory medications, shoe wear modification, ice, and rest. A toe strengthening program is also presented.

Closed reduction of a rare type III dislocation of the first metatarsophalangeal joint

OBJECTIVE

To discuss a rare Type III dislocation of the first metatarsophalangeal (MP) joint, without fracture, that used a closed reduction technique for correction.

CLINICAL FEATURES

A 43-yr-old man suffered from an acute severe dislocation of his great toe as the result of acute forceful motion applied to the toe as his foot was depressed onto a brake pedal to avoid a motor vehicle accident. Physical examination and X-rays revealed the dislocation, muscle spasm, edema and severely restricted range of motion.

INTERVENTION AND OUTCOME

The dislocation was corrected using a closed reduction technique, in this case a chiropractic manipulation. Fourteen months after reduction, the joint was intact, muscle strength was graded +5 normal, ranges of motion were within normal limits and no crepitation was noted. X-rays revealed normal intact joint congruency. The patient experienced full weight bearing, range of motion and function of the joint.

CONCLUSION

Although a Type III dislocation of the great toe has only once been cited briefly in the literature, this classification carries a recommended surgical treatment protocol for correction. No literature describes a closed reduction of a Type III dislocation as described in this case report. It is apparent that a closed reduction technique using a chiropractic manipulation may be considered a valid alternative correction technique for Type III dislocations of the great toe.