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

Hammertoe surgery: arthroplasty, arthrodesis or plantar plate repair?

In cases of painful complex hammertoe deformity, there is no single approach that can be used in all circumstances. If conservative care fails, surgical management may include interphalangeal joint arthroplasty, arthrodesis, and/or plantar plate repair. The best and most pragmatic surgical plan must be patient-centered, taking the age, activity level, expectations of the patient, and precise etiology of the hammertoe deformity into account.

Diagnosis of plantar plate injury by magnetic resonance imaging with reference to intraoperative findings

The objective of the present study was to assess the utility of magnetic resonance imaging in evaluating injury to the plantar plate and to determine whether conventional low-field magnetic resonance imaging is a valid tool for diagnostic evaluation. Magnetic resonance imaging scans of 45 feet in 41 patients (38 females and 3 males, with an average age of 52.1 years) were prospectively evaluated to assess the integrity of the plantar plate ligament and compared with a reference standard of intraoperative findings. The concordance of tear severity observed on magnetic resonance imaging with the intraoperative findings was also assessed using a newly proposed grading scheme for plantar plate injuries. Intraoperatively, 41 plantar plate tears and 4 intact ligaments were found. The accuracy, sensitivity, specificity, positive predictive value, and negative predictive value was 96%, 95%, 100%, 100%, and 67%, respectively. The clinical diagnosis of plantar plate injury was also highly accurate in our study population (41/45, 91%). Finally, we observed moderate concordance between the magnetic resonance imaging grade and surgical grade of plantar plate tear (28/45, 62%), with greater concordance occurring at higher grades. Our results have demonstrated that magnetic resonance imaging is an accurate and valid test for the diagnosing injuries of the plantar plate ligament. Given the high accuracy of the clinical findings, magnetic resonance imaging is most useful when the decision to operate will be sufficiently influenced by either a normal magnetic resonance imaging appearance of the plantar plate or the presence of a high-grade tear.

Lesser metatarsophalangeal joint instability: prospective evaluation and repair of plantar plate and capsular insufficiency

BACKGROUND

Anatomical dissection of the second metatarsophalangeal (MTP) joint suggests that the plantar plate is the major stabilizing structure of the joint due to its central location and multiple important attachments. Many surgical procedures have been recommended when conservative treatment has failed, but some have had limited clinical success. The aim of our prospective study was to show the results obtained in the treatment of a group of patients with plantar plate tears by direct repair through a dorsal approach combined with a Weil metatarsal osteotomy with a minimum followup of 12 months.

METHODS

We prospectively treated 28 patients (55 MTP joints) with lesser MTP joint instability, but only 22 patients (40 MTP joints) were treated by the direct repair of the plantar plate and were included in the study. All of them had initial complaints of acute forefoot pain with the subsequent development of deformity and instability of the MTP joints. All patients were evaluated clinically, radiographically, (plain radiographs and MRI exam), and by MTP joint arthroscopy. With this data, a direct correlation between the clinical staging and the anatomical grading for plantar plate dysfunction of each patient was determined

RESULTS

The plantar plate of the second MTP joint was the most commonly affected joint (63%), and Grade III type tear (transverse and/or longitudinal extension tear) was the most frequent type. With the surgical treatment, we were able to markedly improve the parameters studied (pain, medial or dorsomedial deviation of the toe, joint stability, muscle balance, and joint congruence) to acceptable levels, The AOFAS score improved substantially from an average of 52 points preoperatively to 92 points postoperatively.

CONCLUSION

The direct plantar plate repair combined with a Weil osteotomy and lateral soft tissue reefing can restore the normal alignment of the MTP joint. We have demonstrated that the anatomic repair of the plantar plate can correct the deviation of the affected toe (medial, dorsal, dorsomedial or dorsolateral), which lead to diminished pain with improved functional scores.

Metatarsophalangeal joint pathology in crossover second toe deformity: a cadaveric study

BACKGROUND

Ligamentous and capsular insufficiency of the second metatarsophalangeal joint has been surgically treated for over two decades, mainly with indirect surgical repairs, which stabilize adjacent soft tissue and shorten or decompress the osseous structures. While ligamentous insufficiency has been described and recognized, degeneration of the plantar plate and tears of the capsule have rarely been documented. The purpose of this study was to document and describe the presence and pattern of plantar plate tears in specimens with crossover second toe deformities, and based on this, to develop an anatomical grading system to assist in the assessment and treatment of this condition.

METHODS

Sixteen below-knee cadaveric specimens with a clinical diagnosis of a second crossover toe deformity were examined, and dissected by removing the metatarsal head. The pathologic findings of plantar plate and capsular pathology, as well as ligamentous disruption, were observed and recorded. Demographics of the specimens were recorded, and simulated weightbearing radiographs were obtained prior to dissection so that pertinent angular measurements could be obtained.

RESULTS

Demographics demonstrated a high percentage of female specimens, and a typically older population that has been reported for this condition. Radiographic findings documented a high percentage of hallux valgus and hallux rigidus deformities. The MTP-2 and MTP-3 angles were divergent consistent with a crossover toe deformity. We consistently found transverse tears in the plantar plate region immediately proximal to the capsular insertion on the base of the proximal phalanx. With increasing deformity, wider distal transverse tears extending from lateral to medial were found. Midsubstance tears, collateral ligament tears, and complete disruption of the plantar plate were found in more severe deformities.

CONCLUSION

In this largest series of cadaveric dissections of crossover second toe deformities, we describe the types and extent of plantar plate tears associated with increasing deformity of the second ray. We present, based on these findings, an anatomic grading system to describe the progressive anatomic changes in the plantar plate.

Second MTP joint instability: grading of the deformity and description of surgical repair of capsular insufficiency

A crossover second toe is a commonly seen forefoot problem, usually occurring in women aged > 50 years, and often in association with a bunion deformity. The plantar plate is the principal static stabilizer of the second metatarsophalangeal (MTP) joint. Different authors have proposed classifications to define instability of the second MTP joint, but only describe clinical progression of the deformity. Once a plantar plate tear has developed, conservative treatment can eliminate the symptoms and prevent progression of the deformity but cannot achieve correction or realignment of the deformity. The proposed clinical staging and anatomic grading classification combines clinical findings and anatomic aspects of the plantar plate tears. The surgical treatment described herein reconstructs the anatomic structures that lead to the instability of the second MTP joint. A plantar plate tear repair and lateral soft tissue reefing can restore the normal alignment of the joint with an anatomic repair.

Correction of crossover deformity of second toe by combined plantar plate tenodesis and extensor digitorum brevis transfer: a minimally invasive approach

PURPOSE

To study the efficacy and safety of the combined plantar plate tenodesis and extensor digitorum brevis transfer in correction of claw toe deformity.

METHODS

Between 2007 and 2008, 11 patients (13 feet) underwent combined plantar plate tenodesis and EDB transfer for the correction of crossover second toe deformity. The clinical and radiological results were studied.

RESULTS

There was no more crossover toe deformity in all patients. Two patients had residual mild residual claw toe deformity. The lateral metatarsophalangeal angle in preoperative weight-bearing radiograph averaged 53° ± 5°. The postoperative lateral metatarsophalangeal angle averaged 23° ± 6°. The dorsoplantar metatarsophalangeal angle in preoperative weight-bearing radiograph averaged -9° ± 4°. The postoperative dorsoplantar metatarsophalangeal angle averaged 2° ± 4°.

CONCLUSIONS

Combined plantar plate tenodesis and extensor digitorum brevis transfer is an effective procedure to correct crossover second toe deformity. This is a relatively simple procedure and can be preformed through small incisions with minimal soft tissue dissection.

LEVEL OF EVIDENCE

Level 3 therapeutic study.

Anatomic plantar plate repair using the Weil metatarsal osteotomy approach

The purpose of this study was to analyze the early results of a new technique for anatomic plantar plate repair and advancement using a Weil metatarsal osteotomy of the second metatarsal. The authors retrospectively reviewed medical records of 13 consecutive adult patients (15 feet) who underwent this procedure by a single surgeon. The authors recorded visual analog pain scale scores preoperatively and postoperatively and patient-reported clinical outcome measurement surveys during their final follow-up visit. At an average of 22.5 months (range, 13 to 33 months) follow-up, 11 of 13 patients (85%) reported improved function whereas 10 of 13 (77%) were either satisfied or very satisfied with the outcome. Postoperative scores on the American Orthopaedic Foot and Ankle Society Lesser Metatarsophalangeal- Interphalangeal Scale averaged 85.7 on a scale of 100 (SD = 13.1, 95% CI = 79.1-91.5). Patients reported an average preoperative visual analog pain scale of 7.3 (SD = 1.6, 95% CI = 6.4-8.1) versus an average of 1.7 (SD = 1.8, 95% CI = 0.7-2.7) postoperatively. This was a significant reduction in pain rating (P < .0001, t = 8.9, df = 27). Complications included painful hardware and metatarsalgia. There were no cases of dehiscence, malunion, nonunion, or recurrent metatarsophalangeal joint subluxation. This unique surgical technique addresses metatarsal overload and the instability of the second metatarsophalangeal joint while allowing for anatomic repair of the plantar plate pathology.

Sequential dissection for exposure of the second metatarsophalangeal joint

BACKGROUND

Instability of the second metatarsophalangeal (MTP) joint is relatively common, and although the anatomy of the joint has been well described and plantar plate pathology has been identified, little has been written about its exposure and repair. The goal of this study was to elucidate the necessary dissection to expose and potentially repair the lesions of the plantar plate through a dorsal approach.

MATERIALS AND METHODS

Sequential dorsal dissection of the second MTP joint was carried out in eight cadaveric specimens. After each step, measurements were obtained using fluoroscopic imaging and digital photography to determine the amount of exposure of the plantar plate gained by each step.

RESULTS

Dorsal capsulotomy of the second MTP joint with collateral ligament release off of the proximal phalanx base, then combined with a subcapital oblique metatarsal osteotomy provided on average 8 and 8.5 mm of exposure of the plantar plate as measured by digital photography and fluoroscopy, respectively. Minimal exposure was gained by releasing the collateral ligaments from the metatarsal head or elevating the plantar plate off of the plantar metatarsal head.

CONCLUSION

Exposure of the plantar plate can be obtained by releasing the collateral ligaments off of the proximal phalanx and performing a subcapital oblique osteotomy.

CLINICAL RELEVANCE

Minimizing the risk of disrupting the blood supply to the metatarsal head may be possible by avoiding collateral ligament or plantar plate release.

Plantar plate tears: a review of the modified flexor tendon transfer repair for stabilization

Forefoot pain is one of the most common presenting problems in a foot and ankle practice. One of the most common presenting problems, yet most commonly missed problems, is a plantar plate tear. Often the problem is considered to be potential neuroma, fat pad atrophy, or a generalized diagnosis of metatarsalgia or metatarsal head overload. Unfortunately, not enough attention is placed on the plantar and medial/lateral ligamentous structures of the metatarsal-phalangeal joints. This lack of attention results in poor diagnosis, lack of care, treatment for the wrong condition, and ultimate frustration for the patients and doctor.

Modified plantar plate tenodesis for correction of claw toe deformity

BACKGROUND

The purpose of the study was to evaluate the efficacy and safety of the modified plantar plate tenodesis for correction of claw toe deformity.

MATERIALS AND METHODS

Modified plantar plate tenodesis was performed in ten fresh frozen cadaveric feet with claw toe deformity of the second toe. The plantar plate of the second metatarsophalangeal joint was anchored to the extensor digitorum longus tendon by a figure-of-eight suture. The figure-of-eight construct and the relationship of the digital nerve and the suture were studied. A clinical study was conducted to study the operative times, degree of correction and the improvement of AOFAS score between groups with the original plantar plate tenodesis (Group 1) and modified technique (Group 2). Any neural injury if present was also noted.

RESULT

In the cadaveric study, the claw toe deformity was corrected and no nerve injury occurred in any specimen. There was flexor tendon tethering by the suture in 2 specimens. In the clinical study, the average operative time was 51 minutes for Group 1 and 31 minutes for Group 2. The improvement in AOFAS score averaged 44 in Group 1 and 43 in Group 2. The corrective power of the sagittal plane deformity at the metatarsophalangeal joint averaged 25 degrees in Group 1 and 23 degrees in Group 2.

CONCLUSION

Plantar plate tenodesis was effective in correction of flexible claw second toe deformity by stabilization of the attenuated plantar plate. The modified technique allowed easier retrieval of the suture and shorter operative time. However, it may result in tethering of the flexor tendon.

The laterality of the surgical correction of forefoot pathology

Lateral prevalence has not been traditionally attributed to the development and presentation of pathologic forefoot complaints. The objective of this study was to determine if a laterality prevalence exists for surgically corrected forefoot deformities. All cases performed at the Inova Fairfax Hospital Ambulatory Surgery Center over a 76-month period were reviewed and classified into the following categories: hallux abductovalgus deformity correction, hallux limitus deformity correction, specific digital deformity correction, neuroma surgery, and combinations of these categories (n = 1821). Our analyses indicated no laterality difference in the surgical correction of most common forefoot pathologies. A measure of all examined surgical corrections (hallux abductovalgus, hallux limitus, digital deformity, and/or neuroma) did not demonstrate a difference between the surgical correction of the right and left extremities (chi(2) = 0.003; P = .94). There was also no significant difference in the surgical correction of the right and left extremities when studying the individual categories of any hallux abductovalgus correction (chi(2) = 0.416; P = .52), any hallux limitus correction (chi(2) = 2.050; P = .15), any digital deformity correction (chi(2) = 1.251; P = .26), or any neuroma surgery (chi(2) = 0.784; P = .38). Only the surgical correction of hallux limitus deformity without surgical correction of digital deformity or neuroma demonstrated a significant laterality with surgical correction of the right lower extremity being more common (chi(2) = 4.600; P = .03).

LEVEL OF EVIDENCE

2.

Epidemiological aspects of the surgical correction of structural forefoot pathology

The aim of this study was to associate structural forefoot surgical correction with theories related to the etiology of structural forefoot pathology. All forefoot surgical cases performed at the Inova Fairfax Hospital Ambulatory Surgery Center over a 76-month period (January 2001 through April 2007) were reviewed and classified according to the following surgical categories: hallux abductovalgus, hallux limitus, lesser digital deformity, and combinations of these categories (N = 1684 procedures in 1592 patients). The results suggested that the etiology of lesser digital deformity was associated with the etiology of hallux abductovalgus more so than it was with hallux limitus. In fact, a patient undergoing surgical correction of a hallux abductovalgus deformity displayed 4.63 times greater odds of undergoing surgical correction of a digital deformity, or deformities, compared to a patient undergoing surgical correction of hallux limitus (OR = 4.63, 95% CI 2.81-7.71, P < .0001). Furthermore, medial (second or second and third) toe deformity correction was statistically significantly associated with hallux abductovalgus surgery (OR = 3.34, 95% CI 2.52-4.44, P < .0001), whereas lateral (fifth or fourth and fifth) toe deformity correction was statistically significantly associated with cases that did not involve hallux abductovalgus surgery (OR = 0.27, 95% CI 0.20-0.37, P < .0001). The concept of flexor hallucis longus stabilization is introduced as a possible mechanical explanation for these results.

LEVEL OF EVIDENCE

2.

The role of passive plantar flexion in floating toes following Weil osteotomy

Floating toes are a common complication following Weil osteotomy. The toes are passively plantarflexed via the windlass mechanism, which may play a role in floating toe. Five cadaver lower limb specimens were loaded on a custom frame and 3 different interventions were tested, including control group, Weil osteotomy group, and Weil osteotomy plus plantar plate-shortening group. The extensor tendon to the second toe was loaded with 20 Newtons of tension during the trials, and non-weight-bearing and simulated weight-bearing radiographs were taken to measure the metatarsophalangeal joint extension angle. The extension angle passively plantarflexed 11.20 degrees +/- 3.43 degrees in the control group, 0.40 degrees +/- 0.89 degrees in the Weil osteotomy group, and 8.00 degrees +/- 1.41 degrees in the Weil osteotomy plus plantar plate-shortening group. Comparison of the amount of passive plantarflexion between the groups revealed statistically significant changes between the control and Weil osteotomy groups (P = .0001), and the Weil osteotomy compared with the Weil osteotomy plus plantar plate-shortening (P < .0001); whereas no statistically significant difference was observed between the control and Weil osteotomy plus plantar plate-shortening groups (P = .0893). These results support the idea that the toes undergo passive plantar flexion due to the windlass mechanism, which is dampened by the Weil osteotomy. Dampening of the windlass mechanism may be responsible for floating toe following a Weil osteotomy.

Combined plantar plate and hammertoe repair with flexor digitorum longus tendon transfer for chronic, severe sagittal plane instability of the lesser metatarsophalangeal joints: preliminary observations

The plantar plate provides a substantial static support for the lesser metatarsophalangeal joints. Insufficiency involving tear, attenuation, or absence of this structure can result in significant sagittal plane instability and deformity. When a plantar plate tear is established and is unresponsive to conservative treatment, plantar plate repair is indicated to address symptoms and reestablish static joint stability. The authors hypothesized that combined plantar plate and hammertoe repair with flexor digitorum longus tendon transfer provides a viable surgical option to address chronic plantar plate tears with secondary joint instability and digital deformity. The authors retrospectively evaluated a case series of 18 consecutive patients (20 feet) who underwent this combined surgical strategy as the primary procedure to address severe, chronic sagittal plane instability of the lesser metatarsophalangeal joints. Other procedures were performed concurrently in all cases to address predisposing factors and concomitant deformities. Method of evaluation included a subjective, objective, and radiologic evaluation performed at least 1 year after their surgical procedure. Two rating systems were used: the Lesser Metatarsophalangeal-Interphalangeal Scale from the American Orthopedic Foot and Ankle Society, and another designed by the authors. The average postoperative American Orthopedic Foot and Ankle Society score was 83.2/100 and the average postoperative score with the authors' rating system was 87.7/100. All patients were satisfied with their postoperative result. Study results suggest combined plantar plate and hammertoe repair with flexor digitorum longus tendon transfer to be a viable option to address severe, chronic sagittal plane instability of the internal lesser metatarsophalangeal joints. ACFAS Level of Clinical Evidence: 4.

Arthroscopic-assisted correction of claw toe or overriding toe deformity: plantar plate tenodesis

Hyperextension of the metatarsophalangeal joint is the key component of claw toe deformity. We describe an arthroscopic technique to stabilize the plantar plate and reduce the metatarsophalangeal joint. Under arthroscopic guide, the dorsal capsule is released. The plantar plate is anchored and sutured to the extensor digiturum longus tendon. In case of overriding toe deformity, the medial capsule is also reduced and lateral capsule is plicated under arthroscopic guide.

Radiographic analysis of transverse plane digital alignment after surgical repair of the second metatarsophalangeal joint

We undertook a retrospective cohort study of 51 feet in 49 patients with surgically managed second metatarsophalangeal joint instability, including repair of the crossover second toe deformity. The fundamental intervention consisted of proximal interphalangeal joint arthrodesis combined with second metatarsophalangeal joint relocation and Kirschner-wire transfixation, and this was performed alone or in combination with one of the following additional surgical maneuvers: flexor tendon transfer or flexor set release, flexor plate repair, placement of a plantar-lateral retention suture, extensor tendon transfer, metatarsophalangeal arthroplasty, metatarsal osteotomy, or second-to-third syndactyly. The outcome of interest was the presence of a transverse plane second metatarsophalangeal joint angle of 0 degrees to 15 degrees measured on the late postoperative follow-up radiograph. Overall, the median angular correction for all second metatarsophalangeal joint interventions was 8 degrees , and second-to-third syndactyly yielded the most long-term correction followed by, in descending order of the amount of angular correction, use of the fundamental intervention in combination with metatarsophalangeal joint arthroplasty, placement of a plantar-lateral anchor suture in the flexor plate, metatarsal osteotomy, flexor tendon transfer, flexor plate repair, extensor tendon transfer, and the fundamental intervention as a solitary procedure. A sensitivity analysis indicated that our results were resistant to the influence that an unmeasured variable would impart on the data. The results of this investigation should aid surgeons treating patients with unstable second metatarsophalangeal joints, and can be used in the development of future clinical trials and observational studies that focus on the management of this common deformity.

Sonographic and MRI evaluation of the plantar plate: a prospective study

The purpose of this study was to establish the accuracy of ultrasound in the examination of the plantar plate by comparing it with MRI, or if available, surgical findings. The lesser metatarsophalangeal joint plantar plates of 40 symptomatic and 40 asymptomatic feet (160 asymptomatic and 160 symptomatic plantar plates) were examined with ultrasound and MRI. Patients treated with surgery were chosen on a clinical basis and provided surgical correlation for the imaging techniques. Symptomatic patients with metatatarsalgia and suspected metatarsophalangeal joint instability were referred by an orthopedic foot specialist; asymptomatic feet were obtained either through examination of the contralateral foot of the symptomatic patients or volunteers. Ultrasound detected 75/160 and 139/160 plantar plates torn in the asymptomatic and symptomatic groups, respectively. MRI detected 56/160 and 142/160 tears in the symptomatic and asymptomatic groups, respectively. The sensitivity of MRI and ultrasound with surgical correlation was calculated to be 87 and 96%, respectively, with poor specificity. Ultrasound correlates moderately with MRI in the evaluation of the plantar plate. Surgical correlations, although limited (n = 10), indicate ultrasound is superior to MRI with more accurate detection of tears.

Sonography of Plantar Plates in Cadavers: Correlation with MRI and Histology

OBJECTIVE

The purpose of our study was to describe the sonographic appearance of the lesser metatarsal plantar plates in cadavers and to correlate these findings with MRI and histology.

MATERIALS AND METHODS

Six soft-embalmed cadaveric feet (74-92 years old; two male, one female) were imaged with sonography and MRI. Tear dimensions of the plantar plate were recorded in the long and short axes. Orthopedic surgeons directly inspected the plantar plates before removing samples for histologic correlation. One young fresh cadaver was imaged with sonography before histologic assessment.

RESULTS

The normal plantar plate appearance on sonography was a slightly echoic, homogeneous, curved structure. At direct inspection, a tear was present in 23 (96%) of 24 of the lesser plantar plates in the soft-embalmed feet. This direct inspection correlated with sonography detecting 23 tears correctly and MRI, 22 tears. Both sonography and MRI falsely reported one tear, but MRI also failed to detect one tear. Histologically, the abnormal plantar plate showed loss of the normal dense regular tissue and replacement with vessels, hydropic tissue, and a mixture of loose connective tissue and dense irregular connective tissue.

CONCLUSION

Sonography, being noninvasive, shows promise as an imaging tool of the plantar plate. With ongoing research in this area we hope to determine the reliability and significance of such a technique in the evaluation of the plantar plate.

Hemiphalangectomy and syndactylization for treatment of osteoarthritis and dislocation of the second metatarsal phalangeal joint: an outcome study

End-stage osteoarthritis or severe dislocation at the second metatarsophalangeal joint typically presents with chronic pain and is often unrelieved by conservative treatment. The aim of this article is to review the preliminary outcomes of surgery involving resection of the base of the second proximal phalanx with syndactylization to the third toe for stability. Thirteen patients (13 feet) with second metatarsophalangeal osteoarthritis and 15 patients (15 feet) with a dislocated second toe underwent the procedure and were reviewed after a mean 12.4 months (range, 5-25 months). Patients were evaluated preoperatively and postoperatively with the American Orthopedic Foot and Ankle Society's scoring system and clinical review. A patient questionnaire was devised to yield information regarding toe alignment, cosmesis, and reflection on the procedure. Pain and activities were significantly improved in both subgroups (P < .01). Eighty-two percent were very satisfied or satisfied with the reduction in symptoms, with 11% satisfied with reservations and 7% not satisfied. Seventy-nine percent were very satisfied or satisfied with the appearance. Thirty-nine percent stated the outcome was better than expected, 14% as expected, and 14% felt the result was worse than expected. Twenty-three patients (82%) had no postoperative cosmetic concerns, and 7 patients (25%) felt there was a moderate or severe difference in the alignment with respect to the other toes. In conclusion, syndactylization can significantly improve pain and activity levels and was found to be cosmetically acceptable.

Freiberg's infraction in identical twins: a case report

Freiberg's infraction is an ostechondrosis of a lesser metatarsal head resulting in degeneration of the metatarsophalangeal joint. Several mechanisms have been suggested in its pathenogenesis. Freiberg first described the entity and believed single impact trauma was the underlying cause. Repetitive biomechanical microtrauma is the most widely accepted etiologic theory. Other factors contributing to its development include aseptic necrosis, ischemia, and a congenital predisposition. We present a case report of Freiberg's infraction occurring in identical twins involving multiple metatarsals in various stages of degeneration. One of the twins was affected unilaterally whereas the other twin was affected bilaterally. Both twins had involvement of the second metatarsal on the same side extremity. The occurrence of Freiberg's infraction in identical twins suggests that an underlying congenital predisposition to the condition may play more of a role than previously considered.

Central metatarsal head-neck osteotomies: indications and operative techniques

The author presents the history and indications of various central metatarsal head-neck osteotomies with special emphasis on the radiographic assessment, vascular supply, and regional anatomy. The surgical techniques described include (1) minimal incision osteotomy; (2) Weil metatarsal osteotomy and various modifications; and (3) a novel "telescoping" osteotomy. Ancillary soft-tissue and osseous digital procedures as well as the prevention and management of potential complications are presented in detail.

Second metatarsophalangeal joint arthrography: a cadaveric correlation study

Arthrography of the second metatarsophalangeal joint is an important diagnostic tool to evaluate the integrity of the plantar plate and to aid in the decision process for surgical intervention. A variety of filling patterns have been identified with lesser metatarsophalangeal joint arthrography and their significance with soft-tissue pathology remains to be completely understood. The purpose of this cadaveric study was to evaluate dye patterns in a series of arthrograms of the second metatarsophalangeal joint and to correlate them with identifiable anatomic lesions or structural variants. Thirty-nine cadaveric specimens (including 28 matched pairs) underwent second metatarsophalangeal joint arthrography with a colored radiopaque dye. Arthrographic findings were observed and recorded. Specimens exhibiting dye extravasation outside of the capsular constraints of the joint were dissected to discover any soft-tissue abnormalities. Twenty-one percent of specimens exhibited abnormal extravasation of dye outside of the joint capsule. A plantar plate tear was identified in 2 of these specimens. Filling of the first intermetatarsophalangeal bursa occurred in 6 specimens. However, because this finding was identified in 2 matched pairs, an anatomic variance is suggested rather than a pathologic entity. This cadaveric study shows that anatomic variances exist concerning the second metatarsophalangeal capsule and that arthrography should be correlated with the clinical scenario.

Second metatarsophalangeal joint fusion: a new technique for crossover hammertoe deformity. A preliminary report

The author reports on second metatarsophalangeal joint arthrodesis for the severe crossover hammertoe deformity. Eleven patients underwent an arthrodesis of the second metatarsophalangeal joint with a.062 Kirschner wire intramedullary fixation and a dorsal small bone staple and resection of the proximal phalangeal head of the second digit. Outcomes were retrospectively reviewed at average follow-up time of 19 months. A subjective patient satisfaction survey along with a clinical and radiographic evaluation was undertaken in the postoperative period. Ten of 11 patients scored good to excellent results based on the patient subjective survey at final follow-up. Ten of 11 patients obtained primary arthrodesis. One patient experienced an asymptomatic nonunion. This new technique appears to be reliable for the maintenance of long-term correction of a crossover second toe with arthrodesis of the second metatarsophalangeal joint.

Metatarsophalangeal joint capsule tears: an analysis by arthrography, a new classification system and surgical management

Metatarsalgia is a common presenting symptom with an established list of differential diagnoses. The authors present a classification system and surgical treatment algorithm for chronic metatarsophalangeal pain due to metatarsophalangeal joint capsule tear. A series of 58 metatarsophalangeal joints with partial tear diagnosed by arthrogram and treated by surgical repair are reviewed. The authors propose a classification system based on preoperative arthrography and a surgical repair procedure for each type of three distinct patterns. A study was developed and funded to perform postoperative arthrograms on 15 patients who had undergone surgical repair using the procedures presented. The purpose of the study was to validate the utility of the arthrogram in the diagnosis and clarification of the nature of the capsular tear. The authors were also able to demonstrate that the arthrographic findings became normal postoperatively, and that surgical repair of a seemingly innocuous capsule tear relieves pain. Fifty-six patients in the series reported relief of their preoperative symptoms. Postoperative arthrograms in 15 patients demonstrated a normal pattern in 73%, 20% had decreased extravasation, and 7% were unchanged.

Predislocation syndrome: a review and retrospective analysis of eight patients

Predislocation syndrome is defined as an either an acute, subacute, or chronic inflammatory process involving the lesser metatarsophalangealjoints. If left untreated, this process can lead to plantarplate and capsular attenuation and metatarsophalangeal joint instability. A retrospective analysis were performed on eight patients who were treated with a flexor tendon transfer for this condition. A subjective analysis and chart review were performed to determine the final outcome of these patients. All patients had a chief complaint of a painful second metatarsophalangeal joint with seven of eight patients having an associated hallux valgus deformity. Excellent results were achieved in six patients. Residual stiffness was the primary complaint of two patients following surgery, suggesting that metatarsophalangeal joint stiffness may be a potential problem after flexor digitorum longus tendon transfers. However, we concluded that the flexor digitorum longus tendon transfer remains an excellent procedure for second toe instability and late-stage predislocation syndrome. A literature review describing the epidemiology, symptom complex, physical findings, radiographic signs and therapies used to manage predislocation syndrome were also discussed.

Biomechanics of the first ray. Part III. Consequences of Lapidus arthrodesis on peroneus longus function: a three-dimensional kinematic analysis in a cadaver model

It has long been proposed that first metatarsocuneiform joint (FMCJ) arthrodesis, also known as Lapidus arthrodesis, can realign the first ray and permanently lock the FMCJ to control hypermobility. Left unanswered is the functional consequence of peroneus longus (PL) after such a procedure. In this study, the effects of PL on the medial column of the foot before and after metatarsocuneiform arthrodesis were evaluated. Seven fresh-frozen cadaver specimens with an intact foot and ankle were mounted on a custom-made acrylic frame and loaded to 400 N while midstance motor function was simulated with pneumatic actuators. Three-dimensional radiowave tracking transducers were attached to the first metatarsal, medial cuneiform, navicular, and talus to measure osseous movements while tensile loads of 0% to 100% of PL predicted force was applied. Simulated arthrodesis of the metatarsocuneiform joint and then additionally the intercuneiform 1-2 joint was achieved with titanium pins and then retested to determine any change in effect from PL. Significant frontal plane eversion of the medial cuneiform (p = .016) and dorsiflexion of the talus (p = .045) occurred after Lapidus arthrodesis was achieved. This suggests that arthrodesis at the first metatarsocuneiform joint increases the efficiency of PL stabilizing action on the medial column.

Biomechanics of the first ray. Part II: Metatarsus primus varus as a cause of hypermobility. A three-dimensional kinematic analysis in a cadaver model

Variation in functional stability of the first metatarsocuneiform joint was analyzed between transverse plane deviated (adducted) and corrected first metatarsal positions in a closed kinetic chain model. Six fresh frozen cadaver specimens with intact ankles and feet were fitted with a custom fabricated titanium metatarsal jig, which allowed for manipulation of the first metatarsal in the transverse plane. Specimens were mounted into a custom-made acrylic load frame and axially loaded to 400 N. Radiowave three-dimensional tracking transducers were attached to the following osseous segments: first metatarsal head and base, medial cuneiform, and second metatarsal. A dorsally directed load was applied to the first metatarsal segment and resultant movements were measured. Repeated testing was performed on a transverse deviated and corrected first metatarsal positions with the hallux plantargrade and maximally dorsiflexed to engage the windlass mechanism. With the windlass mechanism engaged and first metatarsal corrected, a 26% increase in first ray plantarflexion occurred from a deviated to a corrected first metatarsal position (p < or = .05). This suggests that the windlass mechanism is more efficient when the first metatarsal, sesamoid apparatus, and hallux position are properly aligned with the orientation of the plantar aponeurosis. Clinically, this may explain the correlation of first ray hypermobility with the progression of bunion severity. Our study validates the earlier work of Hicks and adds additional insight into the functional stability in the medial column of the foot.

The treatment of intermetatarsal neuromas with 4% alcohol sclerosing injections

The cause of intermetatarsal neuromas or intermetatarsal neuritis is unclear; however, the most likely pathogenesis is either a mechanically induced degenerative neuropathy or entrapment of the intermetatarsal nerve as it passes under the transverse intermetatarsal ligament. Treatment of intermetatarsal neuromas includes the very simple method of changing shoe styles, more complex conservative treatments with functional orthotic devices, oral anti-inflammatory medications and cortisone injections, and surgical intervention. In this study, 100 adult patients with previously untreated intermetatarsal neuromas received three to seven injections of a 4% alcohol sclerosing solution every 5-10 days. No additional treatment was provided during the visits. The use of 4% alcohol sclerosing solution showed an 89% success rate. Of the 89 patients who were improved, 82 had complete resolution of symptoms. Eleven patients showed no improvement. The results of this prospective study indicate that the alcohol sclerosis treatment of intermetatarsal neuromas is a viable alternative to serial steroid injections or surgery for persistent symptoms.