Hypermobility of the First Ray: the Cinderella of the measurements conventionally assessed for correction of Hallux Valgus

First metatarsophalangeal joint: Embryology, anatomy and biomechanics

The first metatarsophalangeal (MTP) joint plays a crucial role in foot biomechanics, particularly in weight-bearing activities such as walking and running. It is frequently affected by conditions like hallux valgus (HV) and hallux rigidus, with HV impacting approximately 23%-35% of the population. This narrative review explores the embryology, anatomy, and biomechanics of the first MTP joint (MTPJ), highlighting its significance in maintaining foot stability and function. A comprehensive literature search was conducted using PubMed, Scopus, and Google Scholar, analyzing 50 relevant studies, including 12 clinical trials. The joint's complex structure and mechanical demands make it susceptible to degenerative and structural disorders. Studies indicate that 25%-40% of individuals with HV experience significant pain and functional impairment, affecting mobility and quality of life. Biomechanical stress, abnormal gait patterns, and joint instability contribute to disease progression. Understanding the anatomical and biomechanical properties of the first MTPJ is essential for improving diagnostic and therapeutic approaches. Emerging surgical techniques, such as osteotomy and joint resurfacing, show promise in reducing recurrence rates and enhancing long-term outcomes. Further research is needed to refine minimally invasive interventions and optimize treatment strategies for first MTPJ disorders.

Radiographic and Patient-Reported Outcomes for First Tarsometatarsal Arthrodesis Using an Intramedullary Nail for Hallux Valgus Deformity A Consecutive Case Series

BACKGROUND

First tarsometatarsal (TMT) arthrodesis is one of the most common procedures performed each year for the correction of hallux valgus deformity, and nonunion rates for first TMT arthrodesis are commonly reported to be between 4% and 15%. The purpose of this study was to evaluate the effectiveness of an intramedullary nail system in patients requiring first TMT arthrodesis.

METHODS

An ambispective, multisurgeon, consecutive case series was conducted, in which retrospective and prospective collection of patient-reported outcome measure (PROM) and radiologic data were conducted. Patients who underwent first TMT arthrodesis from July 2019 to July 2022 for hallux valgus deformity with an intramedullary nail system and had adequate records for a minimum of 3 months postoperation (±4 weeks) were included.

RESULTS

Seventy patients were included in the final analysis, with a median prospective PROM follow-up of 1.6 years. There was an overall union rate of 91.4% (64/70 patients). Nine patients required secondary procedures: 4 hardware removals and 5 nonunion revisions. Collected PROMs and radiologic data showed significant improved from preoperative to prospective follow-up (P < .01).

CONCLUSION

First TMT arthrodesis using an intramedullary nail system result in nonunion rates and PROMs comparable to other techniques currently being used.

LEVELS OF EVIDENCE

Level IV: Retrospective Case Series.

The efficacy of shoes modification and orthotics in hallux valgus deformity: a comprehensive review of literature

Hallux valgus (HV) is a frequent forefoot deformity affecting about 23% of adults and 35.7% of people over 65. The exact etiology is not fully understood. The first ray plays a significant role in walking cause it bears the principal amount of weight and maintains the position of the medial arch. Several factors that deteriorate the integrality of the first ray, such as foot deformities, restrictive footwear, and pes planus, may be ascribed to the HV occurrence. Before any surgical correction, conservative treatment should always be initiated first. Currently, there is no consensus that conservative management by shoe modification and foot orthoses could correct the pathology or terminate the clinical worsening of the condition.From a careful analysis of the literature, proper footwear should be a shoe with an adequate length, wide toe box, cushioned sole, and a lowered heel to not increase the load on the metatarsal heads and cause pain. Personalized 3D printed customized toe spreaders may be applied in patients with HV, improving symptoms and bringing pain relief. Compensating the subtalar joint hyperpronation through foot orthoses plays a fundamental role in the HV development, preventing or at least controlling the condition's progress; this, along with weight reduction and regular physical activity.Data obtained suggest that dynamic foot orthoses prefer a biomechanical type with 3/4-length, which is less likely to negatively affect the dorsal or medial pressures, which instead were noted to increase with the sulcus- and full-length orthoses.Although some studies suggest that foot orthoses would favor the correction of HV deformity, results have been very variable and just in few studies appear to correct HV or reduce its progression, improving symptoms and bringing pain relief. In the case of HV surgical correction, orthoses seem to maintain the correct position acquired over time.

Atraumatic Sport-Related Medial Sesamoid Pain: Conservative Treatment Outcome and Magnetic Resonance Imaging Features

Background

This study aimed to evaluate the effectiveness of conservative treatment in selected patients with atraumatic medial sesamoid pain (MSP) that developed during sports activities. The secondary aim was to determine the detailed underlying pathology in patients who did not respond to conservative treatment using magnetic resonance imaging (MRI).

Methods

From March 2015 to August 2022, we prospectively followed 27 patients who presented to our outpatient clinic with atraumatic sports-related MSP. The conservative treatment protocol for MSP included the use of oral analgesics, activity restriction, insole modification, local corticosteroid injections, and boot walker application with crutches. MRI was performed for all patients who experienced persistent pain despite the completion of conservative treatment.

Results

After the completion of the conservative treatment protocol, 48.1% of the patients reported a reduction in pain. Patients with younger age at pain onset (p = 0.001), higher body mass index (p = 0.001), and a bipartite medial sesamoid (p = 0.010) were more likely to experience persistent pain after conservative treatment. The type of sports activity was also a factor since running- and dancing-related MSP tended to respond better to conservative treatment compared to MSP originating from golf, futsal, and weightlifting with squatting. On MRI, 42.8% of patients showed no specific abnormal findings, with signal changes in soft tissues such as the subcutaneous fat and bursa being the most common, followed by intraosseous signal changes of the medial sesamoid bone and chondral or subchondral lesions of the medial sesamoid metatarsal joint (28.6% each).

Conclusions

Conservative treatment was successful in less than half of the patients who experienced MSP due to sports activity. Practitioners should be aware of the numerous possible causes of conservative treatment failure, such as bursitis, medial sesamoiditis, stress fracture, or chondral lesions between the medial sesamoid and metatarsal. MRI evaluation may be helpful in MSP patients who do not respond to conservative treatment.

Comparative effects of modified rotary scarf osteotomy and traditional scarf osteotomy in treating moderate to severe hallux valgus: a retrospective cohort study

BACKGROUND

Traditional Scarf osteotomy (TSO) is an effective procedure with a good record in moderate to severe hallux valgus (MSHV) surgery. In order to overcome shortcomings of TSO, Modified Rotary Scarf osteotomy (MRSO) was introduced in this study, which aimed to compare the clinical and radiological outcome in the patients treated with MRSO or TSO.

METHODS

Of 175 patients (247 feet) with MSHV, 100 patients (138 feet) treated with MRSO and 75 patients (109 feet) treated with TSO were evaluated according to relevant indicators in twenty-four months follow-up. Pre-surgical and post-surgical HVA, IMA, DMAA, MTP-1 ROM, sesamoid grade and AOFAS (American Orthopaedic Foot and Ankle Society) scores and postsurgical complications were evaluated.

RESULTS

Both groups manifested similar baseline characters. The mean follow-up was of 25.9 (range, 22-37) months. Significantly lower IMA, lower Sesamoid grade and higher DMAA at six months, twelve months and twenty-four months post-surgically had been showed in MRSO group compared to TSO group. There was no significant difference in HVA, MTP-1 ROM and AOFAS data at each follow-up time point post-surgically between the two groups. No major complications occurred in either group.

CONCLUSION

MRSO showed comparable results to TSO, and improved IMA and sesamoid grade to a greater extent, with a lower probability of throughing effect. Although DMAA could be increased by MRSO, MRSO could still be a reproducible, non-dangerous and efficacious alternative procedure for treating HV patients which do not have severe DMAA.

Characteristics of hindfoot morphology and ankle range of motion in young women with hallux valgus

BACKGROUND

Hallux valgus occurs more frequently in women as they age; therefore, it is beneficial to prevent hallux valgus in younger women. The purpose of this study was to clarify the characteristics of hindfoot morphology and the range of motion of the ankle joint with hallux valgus in young women.

METHODS

The participants were 140 young women (mean age 18.8 ± 0.6 years). A three-dimensional footprint automatic measurement apparatus was used to measure the hallux valgus angle in the standing position and the arch-height ratio and heel-floor angle (HFA) in the standing and chair-sitting positions. The amount of change in foot morphology owing to differences in posture was calculated. The range of motion of the ankle joint dorsiflexion, plantarflexion, inversion, and eversion was measured. Participants were classified into two groups according to the presence of hallux valgus. Statistical analysis was used to compare hindfoot morphology and range of motion between the two groups, and the correlation between foot morphology and range of motion was investigated depending on the presence of hallux valgus.

RESULTS

With hallux valgus, the HFA tilted inwards (p = 0.010), and the change in the arch-height ratio due to the difference in posture was large (p = 0.021). There was no difference in the range of motion of the ankle joints with or without hallux valgus. In women with hallux valgus, the amount of change in arch height and HFA was correlated with the range of motion of eversion (r = 0.391, p = 0.027; r = -0.362, p = 0.042).

CONCLUSIONS

With hallux valgus, the hindfoot pronated, and the arch height decreased from sitting to standing. Furthermore, the amount of change in the hindfoot and midfoot due to posture was related to the range of motion of eversion.

Establishment and Validation of a Predictive Nomogram for Hallux Valgus with Pain Under the Second Metatarsal

Objective

To investigate the risk factors for hallux valgus complicated with pain under the second metatarsal and construct an effective model and method for predicting hallux valgus complicated with pain under the second metatarsal based on risk factors.

Methods

A total of 545 patients with hallux valgus who were admitted to our hospital were divided randomly into a training set and a validation set. The demographic characteristics, imaging indices and gait test indices of the patients were collected. The risk factors were identified by univariate and multivariate logistic regression analyses. A risk prediction model for hallux valgus with pain under the second metatarsal was established, and the area under the curve (AUC) of the receiver operating characteristic and a decision curve analysis were used for verification and identification. The value of the model was tested in the verification group.

Results

Second metatarsal length, second metatarsal peak pressure, hallux valgus angle (HVA), intermetatarsal angle 1–2 (IMA1–2) and weight were the risk factors for hallux valgus complicated with pain under the second metatarsal. Based on the weighting of these seven risk factors, a prediction model was established. The AUC of the prediction model was 0.84 (95% confidence interval [CI]: 0.802~0.898, P < 0.05), and the results of a Hosmer–Lemeshow test showed a good degree of calibration (χ² = 10.62, P > 0.05). The internal validation of the AUC was 0.83 (95% CI: 0.737–0.885, P < 0.05). The model had obvious net benefits when the threshold probability was 10%–70%.

Conclusion

Second metatarsal length, second metatarsal peak pressure, HVA, IMA1–2 and weight were the risk factors for hallux valgus combined with second metatarsal pain. The risk prediction model for hallux valgus complicated with pain under the second metatarsal based on these seven variables was proven effective.

Level of Evidence

Level III, retrospective comparative study.

Evaluation and Management of Cavus Foot in Adults: A Narrative Review

Objective: Cavus foot is a deformity defined by the abnormal elevation of the medial arch of the foot and is a common but challenging occurrence for foot and ankle surgeons. In this review, we mainly aim to provide a comprehensive evaluation of the treatment options available for cavus foot correction based on the current research and our experience and to highlight new technologies and future research directions. Methods: Searches on the PubMed and Scopus databases were conducted using the search terms cavus foot, CMT (Charcot–Marie–Tooth), tendon-transfer, osteotomy, and adult. The studies were screened according to the inclusion and exclusion criteria, and the correction of cavus foot was analyzed based on the current research and our own experience. At the same time, 3D models were used to simulate different surgical methods for cavus foot correction. Results: A total of 575 papers were identified and subsequently evaluated based on the title, abstract, and full text. A total of 84 articles were finally included in the review. The deformities involved in cavus foot are complex. Neuromuscular disorders are the main etiologies of cavus foot. Clinical evaluations including biomechanics, etiology, classification, pathophysiology and physical and radiological examinations should be conducted carefully in order to acquire a full understanding of cavus deformities. Soft-tissue release, tendon-transfer, and bony reconstruction are commonly used to correct cavus foot. Surgical plans need to be customized for different patients and usually involve a combination of multiple surgical procedures. A 3D simulation is helpful in that it allows us to gain a more intuitive understanding of various osteotomy methods. Conclusion: The treatment of cavus foot requires us to make personalized operation plans according to different patients based on the comprehensive evaluation of their deformities. A combination of soft-tissue and bony procedures is required. Bony procedures are indispensable for cavus correction. With the promotion of digital orthopedics around the world, we can use computer technology to design and implement cavus foot operations in the future.

Pre- and Post-Operative Relationship between Radiological Measures and Clinical Outcomes in Women with Hallux Valgus

The surgical correction of a hallux valgus (HV) deformity improves radiological parameters and clinical outcomes. However, it is not known how these improvements are related between themselves. In this retrospective study, 73 women were assessed preoperatively and 60 months after HV surgical correction. Several radiological parameters were measured: the hallux valgus angle (HVA), I−II intermetatarsal angle (IMA) and sesamoid position. The functional outcomes were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) Hallux Metatarsophalangeal-Interphalangeal (HMI) scale, and patient-reported outcomes (PROMs) were recorded with the Manchester−Oxford Foot Questionnaire (MOXFQ). A pre−post-surgery comparison of radiological and clinical values was performed, the correlation among them was studied and the differences pre−post-surgery in the radiological measurements compared with those for the clinical outcomes were studied. The results show that all the radiological parameters, functional outcomes and PROMs improved significantly from their pre-operative values to the follow-up values. Multivariate regression analysis showed a significant relationship (p < 0.001) between the differential pre−post-surgery AOFAS scoring only with two sesamoid position differential pre−post-surgery measures: position of medial sesamoid (PMS) and translation of the first metatarsal head (TMH). However, no significant association was observed between the pre−post-surgery radiological differences and the pre−post-surgery MOXFQ scoring.

Dislocations of the second and third metatarsophalangeal joints after local steroid injection in patients with refractory metatarsalgia: A case report

Local steroid injections are frequently administered to patients with refractory metatarsalgia. No reports have described dislocation of the second and third metatarsophalangeal joints after local steroid injections. A 46-year-old woman had suffered from metatarsalgia and received multiple local steroid injections for over 2 years. The second and third metatarsophalangeal joints revealed dorsal dislocations on the lateral radiograph. Therefore, collateral ligament reconstruction of the metatarsophalangeal joints was performed. Intraoperative findings suggested that the rupture of the plantar plate may have caused dorsal dislocation of both joints. Thus, unnecessary multiple steroid injections around the lesser metatarsophalangeal joint should be avoided.

A Novel Radiographic Measurement Method for the Evaluation of Metatarsophalangeal Joint Dislocation of the Lesser Toe in Patients with Rheumatoid Arthritis

Dorsal dislocation of metatarsophalangeal (MTP) joints of the lesser toe frequently occurs in patients with rheumatoid arthritis (RA), and may cause painful and uncomfortable plantar callosities and ulceration. The current study examined the reliability and clinical relevance of a novel radiographic parameter (the MTP overlap distance [MOD]) in evaluating the severity of MTP joint dislocation. The subjects of the current study were 147 RA patients (276 feet; 1104 toes). MOD, defined as the overlap distance of the metatarsal head and the proximal end of the phalanx, was measured on plain radiographs. The relationship between the MOD and clinical complaints (forefoot pain and/or callosity formation) was analyzed to create a severity grading system. As a result, toes with callosities had a significantly larger MOD. ROC analysis revealed that the MOD had a high AUC for predicting an asymptomatic foot (−0.70) and callosities (0.89). MOD grades were defined as follows: grade 1, 0 ≤ MOD < 5 mm; grade 2, 5 ≤ MOD < 10 mm; and grade 3, MOD ≥ 10 mm. The intra- and inter-observer reliability of the MOD grade had high reproducibility. Furthermore, the MOD and MOD grade improved significantly after joint-preserving surgeries for lesser toe deformities. Our results suggest that MOD and MOD grade might be useful tools for the evaluation of deformities of the lesser toe and the effect of surgical intervention for MTP joints in patients with RA.