Onychomatricoma Presenting as a Dystrophic Right Great Toenail: Case Report and Review

Onychomatricoma is a rare, benign nail matrix tumor. It most frequently occurs on one of the first three fingers of the dominant hand or the big toe in middle-aged women. Our patient presented with a 10-year history of a progressive thickening of her right great toenail; it bled easily and was intermittently painful. She had experienced trauma to the nail prior to the onset of the dystrophy. MRI primarily showed inflammation localized to the nail bed without bony extension. Excisional biopsy, which included both the nail plate and matrix, established the diagnosis of onychomatricoma originating from the ventral nail matrix (lunula). Nail trauma or fungal infection may have a causative role in the pathogenesis of onychomatricoma. The nail plate can show splitting, increased curvature, or ridging; it can also present with yellow, red or brown, linear, pigmented bands. The clinical differential diagnosis of onychomatricoma includes fibrokeratoma, melanonychia, onychomycosis, periungual fibroma, and squamous cell carcinoma. Dermoscopic imaging shows parallel lesion edges and splinter hemorrhages; these dermoscopic features support the diagnosis of onychomatricoma over squamous cell carcinoma. Imaging such as ultrasound or MRI may suggest the diagnosis. Biopsy of the tumor is necessary to establish the diagnosis; the tumor may derive either from the ventral nail matrix (lunula) or from the ventral surface of the proximal nail fold. Histologic features vary depending not only on tumor origin but also on tissue orientation. Proximally, there is a fibroepithelial tumor consisting of fibrous stalk pierced by epithelial invaginations; the epithelium shows matrical differentiation containing basal and prekeratogenous cells. Distally, the tumor pierces the nail plate as glove-finger digitations; these digitations appear as discrete villi in the nail plate or show their negative image as multiple empty channels that have been described as “worm holes”. The channels may be epithelial lined and contain serous fluid. It is important to obtain an adequate biopsy specimen; the distinctive fibroepithelial histology might be inapparent in partial specimens lacking the epithelial invaginations. Immunohistochemical staining can distinguish onychomatricoma from tumors that can mimic its pathologic changes: fibromyxoma, neurofibroma, and perineurioma. Complete surgical excision is generally curative.

Use of synthetic cartilage implant (Cartiva®) for degeneration of the first and second metatarsophalangeal joint: what is the current evidence?

Polyvinyl alcohol hydrogel implants (also known as Synthetic Cartilage Implant or Cartiva® have been described in the treatment of degeneration of the first and second metatarsophalangeal joint (MTPJ). We reviewed literature to report characteristics of devices on the market and investigate their efficacy and safety. Following the PRISMA checklist, the Medline and Scopus databases were searched, including studies reporting use of Cartiva® for treating joint degeneration of the first and second MPTJ. Studies were searched for surgical technique, postoperative protocol, clinical scores, complications and reoperations. We found that, although some studies suggest that the use of Synthetic Cartilage Implant (Cartiva® is effective in the treatment of hallux rigidus in providing symptoms relief without sacrifice of joint motion, the redundancy of cohorts reported in studies and the frequency of conflict of interest reported by authors weaken the strength of evidence available and warrant further studies. Regarding the treatment of the second MTPJ ailments, no recommendation can be formulated to date due to the lack of primary studies.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

First Metatarsophalangeal Joint Space Area Decreases Within 1 Month After Implantation of a Polyvinyl Alcohol Hydrogel Implant: A Retrospective Radiographic Case Series

In 2016, the U.S. Food and Drug Administration approved the first and only polyvinyl alcohol hydrogel implant for the treatment of hallux rigidus. The implant functions as a bumper to maintain first metatarsophalangeal joint space to prevent contact of the phalangeal base with the first metatarsal head. Short-term and intermediate outcomes with this implant have reported positive outcomes with no radiographic outcomes of implant wear or subsidence. We performed a retrospective radiographic review of 27 consecutive patients who received the implant and measured preoperative and postoperative joint space area (JSA). We found a significant improvement in JSA (p < .001) between the preoperative JSA and JSA at the first postoperative visit at 1 to 2 weeks. We also found a significant decrease in JSA (p < .001) between the first postoperative visit and the second postoperative visit at 5 to 12 weeks. This information could have further implications for implant design as well as how we can better achieve functional improvements in the first metatarsophalangeal joint in patients with hallux rigidus.

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

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

Plantar Partial Pressure Analysis in a Patient with Reverse Extensor Digitorum Brevis Flap for the Treatment of Hallux Injury

Introduction

An extensor digitorum brevis (EDB) flap can be used to cover a small soft-tissue defect and has been widely used as pedicled flap to cover defects around the ankle and foot. However, its post-operative functional recovery is unknown. Few reports have evaluated gait after foot flap surgeries, although gait assessment is considered to be necessary for functional evaluation after foot reconstruction. We performed a reverse EDB flap to treat a right hallux injury and conducted a plantar partial pressure (PPP) analysis as a postoperative functional evaluation.

Case Report

A 30-year-old laborer suffered an injury resulting in necrosis of the distal phalanx and soft-tissue defect of the proximal phalanx. After amputation, the proximal phalanx was covered with a reverse EDB flap. PPP analysis involved a 4-m-long platform system (P-Walk) and was conducted 3- and 12-month post-surgery. Walking velocity and the single-support phase on the affected limb had increased markedly after 12 months. After 12 months, the PPP of the first metatarsal head was greater than on the unaffected side, and the cadence and single-leg support rate were equal to the unaffected side.

Conclusion

A nearly normal gait was obtained by covering the basal part of the hallux with an EDB flap and preserving the metatarsophalangeal joint.

Rate of Development of Hallucal Interphalangeal Degenerative Joint Disease After First Metatarsophalangeal Joint Arthrodesis: A Retrospective Radiographic Analysis

The development of hallux interphalangeal joint (IPJ) arthritis after an arthrodesis of the first metatarsophalangeal joint has been established in the literature. However, the significance has not been well reported. A retrospective, radiographic review of patients who had undergone a first metatarsophalangeal joint arthrodesis was performed. The Coughlin classification for degree of arthritic degeneration, hallux abductus angle, and hallux interphalangeus angle were measured in 107 radiographs of 103 patients preoperatively and postoperatively. Postoperative angles were measured immediately following surgery at approximately 6 weeks, 3 months, 6 months, 12 months, and 24 months. We found that the hallux abductus angle had decreased in the patients postoperatively; however, the hallux abductus interphalangeus angle increased on average after first metatarsophalangeal fusion. The majority of patients started with a Coughlin classification I of the hallux IPJ, which remained unchanged over the postoperative period, with no statistically significant difference in IPJ degeneration in the patients with or without fusion of the first metatarsophalangeal joint. In addition, no patients had a symptomatic hallux IPJ postoperatively within our limited study period. Further prospective studies would be beneficial with longer follow-up times to assess IPJ degeneration following first metatarsophalangeal joint fusions. Levels of Evidence: Level III: Retrospective, comparative study.

Is Fibular Sesamoidectomy a Viable Option for Sesamoiditis? A Retrospective Study

Background Pathologic conditions of the sesamoids can be a source of disabling pain for patients, particularly during toe-off. Some underlying causes include osteonecrosis, inflammation, arthritis, and fracture. Nonoperative treatment is the initial standard of care, and has demonstrated satisfactory outcomes overall; however, operative management may be indicated in cases of pain refractory to conservative management. Sesamoidectomy is an uncommon procedure with risk of potential complications, but may be warranted in select cases of failed nonoperative treatment. Methods A retrospective chart review was conducted at one institution from 2009 to 2018. Twelve patients diagnosed with fibular sesamoiditis were treated with sesamoidectomy. Baseline patient demographics as well as postoperative outcomes were recorded. Results All 12 patients underwent fibular sesamoidectomy using the plantar approach following which their symptom (pain) resolved. Average follow-up for this cohort was 35 months. Of the sample, two patients experienced transient neuritis, one patient developed a superficial infection, and one had painful postoperative scarring. Hallux varus deformity was not observed in any patients. Conclusion Fibular sesamoidectomy may be a safe, viable procedure for patients with sesamoiditis who fail conservative measures.

Falls rate increase and foot dorsal flexion limitations are exhibited in patients who suffer from asthma: A novel case-control study

Purpose: Based on the possible association between reduced foot dorsiflexion and high risk of falls, the main objective was to determine the ankle and 1º metatarsophalangeal joint (1^stMTTP) dorsiflexion range of motion and falls rate in patients with asthma compared to healthy matched-paired controls. Methods: A case-control study was carried out. Eighty participants were recruited and divided into patients with asthma (case group; n=40) and matched-paired healthy participants (control group; n=40). Foot dorsal flexion range of motion (assessed by the Weight-Bearing Lunge Test [WBLT]) and falls rate (evaluated as falls number during the prior year) were considered as the primary outcomes. Indeed, ankle dorsiflexion was measured by a mobile app (º) and a tape measure (cm) as well as 1^stMTTP dorsiflexion was determined by and universal goniometer (º). Results: Statistically significant differences (P<.05) showed that patients with asthma presented a greater falls rate than healthy participants and reduced bilateral ankle and 1^stMTTP dorsiflexion ranges of motion than healthy participants, except for the left ankle dorsiflexion measured as degrees (P>.05). Conclusions: These study findings showed that a falls rate increase and bilateral foot dorsal flexion limitations of the ankle and 1^stMTTP joints are exhibited in patients who suffer from asthma.

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

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

Turf toe: A clinical update

Turf toe is a condition that describes injury to the plantar metatarsophalangeal-sesamoid complex of the great toe.

It is a relatively rare and debilitating condition, particularly seen in American footballers after the introduction of harder, artificial ‘turf’ surfaces.

Turf toe represents a significant injury to the hallux and requires a high index of suspicion.

If unrecognized, it can lead to chronic problems including reduced push-off strength, persistent pain, progressive deformity and eventual joint degeneration.

Patients with chronic injuries may have worse outcomes, and therefore early, accurate diagnosis and initiation of treatment play a vital role.

A multidisciplinary team approach is key for successful return to sport.

Cite this article: EFORT Open Rev 2018;3:501-506. DOI: 10.1302/2058-5241.3.180012

Hallux Interphalangeal Arthrodesis Following First Metatarsophalangeal Arthrodesis

BACKGROUND

Hallux interphalangeal (IP) arthritis can occur after first metatarsophalangeal (MTP) arthrodesis. IP arthrodesis is a standard treatment, but in the setting of prior MTP surgery there will be increased stress on the IP joint. This may result in diminished potential for bone healing. This investigation assessed the outcomes of hallux IP arthrodesis after first MTP arthrodesis.

METHODS

Charts were retrospectively reviewed for patients who underwent interphalangeal arthrodesis between January 1, 2007, and April 3, 2017, and who had a minimum of 12 weeks of follow-up. We compared patients with and without prior ipsilateral first MTP arthrodesis. There were 42 patients whose median follow-up was 9 (range, 3-135) months.

RESULTS

Median time from previous first MTP arthrodesis until IP arthrodesis was 54 months. Six nonunions (35.3%) occurred in 17 patients with prior first MTP arthrodesis. Only 2 nonunions (8.0%) occurred in 25 patients with isolated IP arthrodesis. The multivariable risk difference of nonunion was 53.3% ( P = .001). Prior first MTP arthrodesis also was more likely to have complications (52.9% vs 24.0%, respectively). The multivariable risk difference of complications was 35.7% ( P = .082). The speed of bone healing was significantly different, with a multivariable rate ratio of 0.21 ( P = .012). Conclusion Prior first MTP arthrodesis resulted in 4.8 times slower bone healing for IP arthrodesis. It increased the risks of nonunion and any other complications.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level IV, case series.

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

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

[Turrett's exostoses: about 35 casesk]

Nous rapportons à travers une étude rétrospective faite de 35 cas d’exostose sous unguéale de l’hallux dite exostose de Turrett's colligée entre 1995 et 2015 au service d’Orthopédie Traumatologie de l’Hôpital Militaire Principal d’Instruction de Tunis les résultats de la prise en charge de cette pathologie faite d’adultes jeunes d’âge moyen de 29 ans avec un sexe ratio de 1,7. Le délai moyen de consultation est de 18 mois. Ce retard de consultation est expliqué par une errance diagnostique en rapport avec une ressemblance du tableau clinique avec celui d’un ongle incarné. Le diagnostic est toujours confirmé par une radiographie de face et de profil de l’orteil intéressé. Le traitement a consisté en une exérèse radicale de l’exostose soit à travers une large fenêtre unguéale soit par un abord latéro-unguéal. L’examen anatomopathologique est systématique. Il a permis de confirmer la bénignité de l’affection dans tous les cas. La guérison a été de règle dans tous les cas avec une reprise de l’activité antérieure en 2 mois en moyenne. Aucune récidive n’a été notée.

Measuring Visualized Joint Surface in Hallux Metatarsophalangeal Arthroscopy

BACKGROUND

Arthroscopy has been increasingly used to evaluate small joints in the foot and ankle. In the hallux metatarsophalangeal (MTP) joint, little data exist evaluating the efficacy of arthroscopy to visualize the articular surface. The goal of this cadaveric study was to determine how much articular surface of the MTP joint could be visualized during joint arthroscopy.

METHODS

Ten fresh cadaveric foot specimens were evaluated using standard arthroscopy techniques. The edges of the visualized joint surface were marked with curettes and Kirschner wires; the joints were then surgically exposed and imaged. The visualized surface area was measured using ImageJ^® software.

RESULTS

On the distal 2-dimensional projection of the joint surface, an average 57.5% (range, 49.6%-65.3%) of the metatarsal head and 100% (range, 100%-100%) of the proximal phalanx base were visualized. From a lateral view of the metatarsal head, an average 72 degrees (range, 65-80 degrees) was visualized out of an average total articular arc of 199 degrees (range, 192-206 degrees), for an average 36.5% (range, 32.2%-40.8%) of the articular arc.

CONCLUSION

Complete visualization of the proximal phalanx base was obtained. Incomplete metatarsal head visualization was obtained, but this is limited by technique limitations that may not reflect clinical practice.

CLINICAL RELEVANCE

This information helps to validate the utility of arthrosocpy at the hallux metatarsophalangeal joint.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level IV, retrospective case series.

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

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

Partite hallux sesamoid bones: Relationship with sesamoid bones at other metatarsophalangeal joints

Partite hallux sesamoids are clinically meaningful but their association with other sesamoids is not clear. The objective was to relate the prevalence of the partite hallux sesamoid bones to sesamoid bones at other metatarsophalangeal (MTP) joints. We conducted a retrospective review of plain radiographs of 7946 adult feet between November 2005 and September 2012 to identify partite hallux sesamoids and sesamoids at other MTP joints. Coexistence patterns of the partition and extra sesamoids were studied. Presence or absence of sesamoids at other MTP joints as well as sex and laterality were compared between the feet with and without partite hallux sesamoids using Pearson Chi-square test. Association between age and partition was evaluated using Spearman's correlation coefficient. Overall partite prevalence rate is 6.82%, and coexistence with extra MTP sesamoids was 0.42%. One pattern was partition in hallux sesamoid only, and 4 patterns were coexistence with extra sesamoids. The prevalence rates of partite hallux sesamoids were 7.17% (508/7081) and 3.93% (34/865) in feet without and with extra sesamoids, respectively. The relative risk of 1.889 (95% CI, 1.325-2.693) of partite hallux sesamoids was noted in feet without than with extra sesamoids (Χ² = 12.759, P < 0.001). A negative correlation between age and distribution of partition was identified (r = -0.061, P < 0.001). Partition of hallux sesamoid bones is a developmental variation, it can coexist with sesamoids at other MTP joints following a certain pattern; and its prevalence rate is almost twice higher in feet without than with extra MTP sesamoids. Anat Rec, 2017. © 2017 Wiley Periodicals, Inc. Anat Rec, 301:34-38, 2018. © 2017 Wiley Periodicals, Inc.

Measuring Joint Flexibility in Hallux Rigidus Using a Novel Flexibility Jig

BACKGROUND

The flexibility of the first metatarsophalangeal (MTP) joint in patients with hallux rigidus (HR) has not been studied. Compared to measuring range of motion alone, measures of joint flexibility provide additional information that may prove useful in the assessment of HR. The purpose of this study was to assess the flexibility of the hallux MTP joint in patients with HR compared to controls using a novel flexibility device.

METHODS

Fifteen patients with Coughlin stage II or III HR and 20 healthy controls were recruited prospectively. Using a custom flexibility jig, each of 2 raters performed a series of seated and standing tests on each subject. Dorsiflexion angle and applied torque were plotted against each other to generate 5 different parameters of flexibility. Differences between (1) HR patients and controls and (2) the sitting and standing testing positions were assessed with t tests. Intrarater test-retest reliability, remove-replace reliability, and interrater reliability were assessed with intraclass correlation coefficients (ICCs).

RESULTS

Patients in the HR group were older than patients in the control group ( P < .001) and had lower maximum dorsiflexion ( P < .001). HR patients were less flexible as measured by 3 of the 5 flexibility parameters: early flexibility (first 25% of motion; P = .027), laxity angle ( P < .001), and torque angle ( P = .002). After controlling for age, only laxity angle differed significantly between HR patients and controls ( P < .001). Generally, patients were more flexible when seated compared to standing, with this effect being more marked in HR patients. All parameters had good or excellent intra- and interrater reliability (ICC ≥ 0.60).

CONCLUSIONS

Hallux MTP joint flexibility was reliably assessed in HR patients using a flexibility device. Patients with HR had decreased flexibility of the hallux MTP joint compared to control patients.

LEVEL OF EVIDENCE

Level II, prospective comparative study.

Outcomes of the Distal Metatarsal Dorsiflexion Osteotomy for Advanced Hallux Rigidus

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level IV, prospective case series.

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

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

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level III, comparative series.