Limited Evidence to Support the Use of Intra-Articular Injection of Hyaluronic Acid for the Management of Hallux Rigidus: A Systematic Review.

Background: The purpose of this systematic review was to evaluate outcomes following intra-articular injection of hyaluronic acid (HA) for the treatment of hallux rigidus. Methods: During April 2024, a systematic review of the MEDLINE, EMBASE, and Cochrane Library databases was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data collected and analyzed were number of patients, patient age, follow-up, subjective clinical outcomes, complications, and failures. Results: Five studies were included. In total, 218 patients (218 feet) underwent intra-articular injection of HA at a weighted mean follow-up time of 4.4 ± 1.4 months (range, 3-6). There was an improvement in postinjection visual analog scale (VAS) pain at rest scores, VAS pain during activity scores, American Orthopaedic Foot & Ankle Society (AOFAS) scores, and Foot Health Status Questionnaire (FHSQ) scores. In total, 21 complications (10.0%) were observed, the most common of which was transient postinjection pain in 20 patients (9.6%). There were 7 patients (3.2%) who underwent secondary procedures (3.2%). One randomized control trial (RCT) demonstrated no difference in outcomes between an intra-articular injection of HA compared to an intra-articular injection of saline. One RCT demonstrated superior FHSQ scores following between an intra-articular injection of HA compared to an intra-articular injection of triamcinolone acetonide. Conclusion: This systematic review suggests that intra-articular injection of HA for the treatment of hallux rigidus may lead to improved clinical outcomes with a low complication rate at short-term follow-up. However, the low level and quality of evidence underscores the need for further high-quality studies to be conducted to identify the precise role of HA in the treatment of hallux rigidus.

Primary Isolated Arthrodesis of the First Metatarsophalangeal Joint for Hallux Rigidus: Clinical, Radiologic, and Pedobarographic Evaluation.

Background: Arthrodesis of the first metatarsophalangeal joint is an effective treatment of advanced hallux rigidus. Numerous options have been described for performing this intervention. The aim of this study was to evaluate the outcomes following a consistent surgical technique of joint preparation with hand tools and fixation with 2 crossed screws and a dorsal compression plate. Methods: Thirteen patients (16 feet) who underwent primary isolated arthrodesis of the first metatarsophalangeal joint between March 2019 and June 2021 were available for clinical, radiologic, and pedobarographic evaluation at a minimum of 12 months after surgery. American Orthopaedic Foot & Ankle Society scores, numerical pain rating scale, the radiologic hallux valgus and intermetatarsal 1-2 angles as well as the distribution of plantar pressure during gait were compared between the pre- and postoperative conditions. Results: After an average follow-up period of 26 months, union was achieved in all cases and the mean AOFAS score raised significantly by 39 points. All the patients were satisfied with the result. Only 1 patient complained of mild residual pain at walk. Hardware removal was performed in 2 cases. The mean hallux valgus angle dropped from 12.3 to 6.3 degrees. The mean postoperative dorsiflexion angle was 21.6 degrees. After the procedure, peak pressure was significantly higher beneath the first metatarsal head and heel, whereas pressure-time integral was significantly lower beneath the hallux and medial lesser toes. Conclusion: Arthrodesis of the first metatarsophalangeal joint with 2 crossed screws and a dorsal compression plate is a safe and effective treatment of advanced hallux rigidus. This procedure provides adequate pain relief and functional improvement of gait. Level of Evidence: Level IV, therapeutic, retrospective case series.

Effect of co-morbidities on outcomes of first metatarsophalangeal joint fusion: A systematic review.

Introduction: The pre-existing co-morbidities have a major impact on the outcomes of Orthopaedic procedures as shown by the several studied in various contexts. However, the specific influence of these co-morbidities on first metatarsophalangeal joint fusion remains relatively underexplored. This study aims to address this gap by examining the association between co-morbidities such as obesity, smoking, diabetes, advancing age, and rheumatoid arthritis, and the outcomes of first metatarsophalangeal joint fusion. Methods: A comprehensive search was conducted across multiple databases, including MEDLINE, EMBASE, and CINAHL. Relevant articles were identified and processed using Covidence, with independent assessment conducted to ensure inclusion criteria were met. The focus of the review was on analysing the effects of specific co-morbidities on fusion outcomes. Results: Seven qualifying studies were identified for full-text extraction, revealing significant heterogeneity across the literature, which hindered direct statistical comparisons. The findings presented inconclusive effects of obesity on fusion outcomes, with ambiguous impacts observed for diabetes mellitus and smoking. Additionally, no discernible variance was observed in functional outcomes across different age groups. Furthermore, steroid usage in rheumatoid arthritis cases demonstrated delayed fusion in revision procedures, while primary outcomes remained uncertain. Conclusion: This systematic review highlights the need for further research with standardised methodologies to better understand the correlation between pre-existing co-morbidities and outcomes in first metatarsophalangeal joint fusion. By elucidating these relationships, clinicians can better tailor treatment approaches and optimise patient care in this specific Orthopaedic context. Level of evidence: Level III.

Nonunion After First Metatarsophalangeal Joint Arthrodesis: The Association With Shoe Size.

INTRODUCTION: First metatarsophalangeal joint (MTPJ) arthrodesis is a common treatment for various foot conditions, with nonunion as a frequent complication. The incidence of nonunion varies widely in the literature. In particular, males have a higher risk of nonunion than females. This is possibly due to biomechanical and anatomical differences, as men have on average larger feet than women. This study therefore aims to explore whether shoe size, as a proxy for foot size, affects nonunion rates and could explain the gender disparity in nonunion rates. METHODOLOGY: An exploratory analysis of retrospectively collected data from patients who underwent primary first MTPJ arthrodesis in a single secondary hospital between January 2012 and December 2019. Additional data on body weight, height, and shoe size were prospectively collected from patients. RESULTS: Among 261 included patients, 57 (21.8%) experienced nonunion. Nonunion incidence was higher in males (18, 26.9%) than in females (39, 20.1%). Self-reported shoe size showed no significant association with nonunion in both univariate and multivariate analyses. DISCUSSION: The study's findings suggest that shoe size, as a proxy for foot size, is not associated with nonunion after the first MTPJ arthrodesis. Despite observing a gender difference in nonunion rates, this disparity could not be explained by shoe size. CONCLUSIONS: Shoe size as a proxy for foot size appears to have no clinical association with nonunion following the first MTPJ arthrodesis.

Classification and Radiology.

The classification systems of hallux rigidus, including the Coughlin and Shurnas, Hattrup and Johnson, Regnauld, and Roukis classifications, allow for a comprehensive understanding of the condition's severity and aid in informed treatment decisions. The common techniques of radiological imaging, such as standard plain film radiographs, MRI, magnetic resonance arthrography computed tomography (CT), weightbearing CT, and ultrasound, which enable accurate assessment of joint degeneration and associated pathologies for optimal patient care, are reviewed.

Managing Hallux Rigidus in the Elite Athlete.

Hallux rigidus can present a difficult problem to both competitive and elite athletic populations. Once an appropriate diagnostic workup has been performed, nonoperative management strategies, including anti-inflammatory medications, injection therapies, shoewear modifications, and orthotic devices, represent the mainstay conservative management options. Surgical management can be considered where an athlete's athletic performance is limited. A joint-sparing cheilectomy can provide a predictable return to sport at the most elite levels. The addition of a proximal phalangeal osteotomy can be considered when necessary. Arthroplasty or arthrodesis techniques can be used for persistent symptoms or progressive disease, but with less predictable outcomes.

Dorsal Cheilectomy.

Dorsal cheilectomy refers to a surgical resection of the dorsal osteophyte from the first metatarsal head. It is most often performed in patients with hallux rigidus, who have little to no midrange pain of the first metatarsophalangeal joint. The procedure is simple, quick, and maintains range of motion. Additional advantages of this procedure include low morbidity, quicker postoperative recovery, avoidance of costly implants, and the fact that the procedure does not inhibit future conversion to an arthrodesis. These proposed advantages have led some authors to advocate for the use of a cheilectomy, even in patients with more extensive disease.

Metatarsophalangeal Arthroplasty in Hallux Rigidus.

First metatarsophalangeal joint (MTPJ) arthroplasty provides hallux rigidus patients with pain relief and preserved motion, offering an alternative to arthrodesis. Recent advancements in implant technology and surgical techniques have broadened treatment options. Although good outcomes have been documented in the literature, concerns persist regarding increased complications, uncertain long-term efficacy, and challenges in managing failed arthroplasties. Addressing bone loss resulting from the procedure further complicates salvage procedures. Larger cohorts and extended studies are necessary to establish efficacy of first MTPJ arthroplasty. Decisions must weigh the trade-offs between pain relief and potential complications, requiring thorough patient-surgeon discussions.

Surgical Management of Failed First Metatarsophalangeal Joint Arthroplasty.

This article describes the etiology, clinical presentation, surgical management, and outcomes for treatment of the failed first metatarsophalangeal (MTP) joint arthroplasty. Failure following implant arthroplasty typically creates large osseous deficits and surgical management can be difficult. Salvage arthrodesis provides reliable joint stability while maintaining hallux length. Outcomes following conversion of a failed MTP joint arthroplasty to MTP joint arthrodesis have demonstrated consistent pain relief and high satisfaction: however, high rates of complication and nonunion have been reported. Bone graft may be necessary to fill large voids in the joint. Other revision options for failed arthroplasty have been described, but outcomes remain inconsistent and varied. Ultimately, conversion to MTP joint arthrodesis is the recommended intervention for treatment of the failed MTP arthroplasty implant, providing sufficient stability and pain relief.

Outcomes following minimally invasive dorsal cheilectomy for hallux rigidus: A systematic review.

BACKGROUND: Cheilectomy of the 1st metatarsophalangeal joint (MTPJ) is one of the most common procedures for the management of hallux rigidus. However, there is no consensus regarding outcomes following minimally invasive dorsal cheilectomy (MIDC) for the management of hallux rigidus. AIM: To evaluate outcomes following MIDC for the management of hallux rigidus. METHODS: During November 2023, the PubMed, EMBASE and Cochrane Library databases were systematically reviewed to identify clinical studies examining outcomes following MIDC for the management of hallux rigidus. RESULTS: Six studies were included. In total, 348 patients (370 feet) underwent MIDC for hallux rigidus at a weighted mean follow-up of 37.9 ± 16.5 months. The distribution of patients by Coughlin and Shurna's classification was recorded in 4 studies as follows: I (58 patients, 27.1%), II (112 patients, 52.3%), III (44 patients, 20.6%). Three studies performed an additional 1st MTPJ arthroscopy and debridement following MIDC. Retained intra-articular bone debris was observed in 100% of patients in 1 study. The weighted mean American orthopedic foot and ankle society score improved from a preoperative score of 68.9 ± 3.2 to a postoperative score of 87.1. The complication rate was 8.4%, the most common of which was persistent joint pain and stiffness. Thirty-two failures (8.7%) were observed. Thirty-three secondary procedures (8.9%) were performed at a weighted mean time of 8.6 ± 3.2 months following the index procedure. CONCLUSION: This systematic review demonstrated improvements in subjective clinical outcomes together with a moderate complication rate following MIDC for the management of hallux rigidus at short-term follow-up. A moderate re-operation rate at short-term follow-up was recorded. The marked heterogeneity between included studies and paucity of high quality comparative studies limits the generation of any robust conclusions.

Human foot muscle strength and its association with sprint acceleration, cutting and jumping performance, and kinetics in high-level athletes.

The primary objective of this study was to investigate the relationship between metatarsophalangeal joint (MTPj) flexion torque and sprint acceleration, cutting and jumping performance, and kinetics. A secondary aim was to explore this relationship when MTP flexion strength was associated with other foot and lower limb neuromuscular outputs. After an initial MTPj flexion torque assessment using a custom-built dynamometer, 52 high-level athletes performed the following tasks on a force platform system: maximal sprint acceleration, 90-degree cutting, vertical and horizontal jumps, and foot-ankle hops. Their foot posture, foot passive stiffness and foot-ankle reactive strength were assessed using the Foot Posture Index, the Arch Height Index Measurement System and the Foot-Ankle Rebound Jump Test. Ankle plantarflexion and knee extension isometric torque were assessed using an isokinetic dynamometer. During maximal speed sprinting, multiple linear regressions suggested a major contribution of MTPj flexion torque, foot passive stiffness and foot-ankle reactive strength to explain 28% and 35% of the total variance in the effective vertical impulse and contact time. Ankle plantarflexor and quadriceps isometric torques were aggregately contributors of acceleration performance and separate contributors of cutting and jumping performance. In conclusion, MTPj flexion torque was more strongly associated with sprinting performance kinetics especially at high-speed.

Polyvinyl Alcohol Hydrogel Hemiarthroplasty of First Metatarsophalangeal Joint Hallux Rigidus.

Background Hallux rigidus (HR) is the most common arthritic condition of the foot. Although first metatarsophalangeal joint (MTPJ) arthrodesis has been the historical gold-standard treatment, polyvinyl alcohol (PVA) hydrogel implants have gained popularity as a joint-sparing technique. However, recent studies have shown variable failure rates of PVA hydrogel implants. The purpose of this study was to report the five-year experience with PVA hydrogel implants performed by a single surgeon. Methodology Health records were queried from August 2016 to 2021 for patients who underwent primary PVA hydrogel implant hemiarthroplasty for symptomatic late-stage HR. Patient demographics and postoperative outcomes variables were evaluated. Kaplan-Meier analysis was used to evaluate implant survival. A total of 146 PVA hydrogel implant procedures were performed with a minimum six-month follow-up. Results The majority of patients were female (n = 103, 70.5%), with a mean age of 58.1 (±10.1) years, body mass index of 27.3 (±5.2) kg/m2, and American Society of Anesthesiologists score <3 (n = 131, 89.7%). The majority had stage II or III disease (n = 115, 78.8%). Patients experienced significant improvement in visual analog scale score (p < 0.0001) and hallux dorsiflexion (p = 0.0005). There were 22 (15.1%) complications, including implant subsidence (n = 15, 10.3%), deep infection (n = 6, 4.1%), and hypertrophic ossification (n = 1, 0.7%). Revision surgeries were required in 12.3% (n = 18) of patients at an average of 9.4 (±9.2) months postoperatively. This included nine (6.2%) revision PVA hydrogel implant procedures and nine (6.2%) first MTJP arthrodesis. The one- and two-year survival rates for MTPJ arthrodesis (n = 9) were 95.9% and 86.3%, respectively. Conclusions In the largest single-surgeon series reported, first MTPJ hemiarthroplasty with a PVA hydrogel implant significantly improved pain and hallux dorsiflexion at an average of 14.5 months postoperatively. There was a high two-year survivorship of 86.3% until failure which required first MTPJ arthrodesis. Future studies should be performed to refine the indications for PVA hydrogel implants and identify risk factors.

Outcomes of Surgical Management of Turf Toe: 12-Year Results.

Background "Turf toe" is a classical capsuloligamentous injury to the plantar surface of the metatarsophalangeal (MTP) joint of the great toe. The name is synonymous with injuries sustained on artificial turf or hard grounds. The classical injury pattern is a hyperdorsiflexion injury with an axial load. The outcomes of these injuries are unpredictable and there are no clear guidelines for the management of these injuries. These injuries are debilitating and can lead to long-term problems and inability to return to pre-injury activity level if missed. We present a long-term surgical follow-up of severe grade 3 turf toe injuries. Methods In the period from 2011 to 2022, we treated 20 patients with turf toe/MTP joint instability. There were 10 football injuries (50%), six running injuries (30%), two gymnastic injuries (10%), one motorcycle injury (0.5%), and one was a ballet dancer (0.5%). All the grade 1 and 2 injuries were treated conservatively with rest, ice application, and splinting of the toe. Grade 3 injuries were treated surgically and strict rehabilitation protocol was followed. Results The mean age at surgery was 32.7 years and the average patient follow-up was 7.5 months after surgery. The Manchester-Oxford Foot Questionnaire (MOXFQ) score showed a statistically significant improvement from a mean of 73.0 (median = 75) preoperatively to 28.1 (median = 28.6) postoperatively (median improvement = 46.4, P = 0.022). Similarly, there was a significant improvement in pain score, which showed an improvement from a mean of 72.9 (median = 70.0) preoperatively to a mean of 22.9 (median = 25.0) postoperatively (median improvement = 51.3, P = 0.022). Conclusion Turf toe is a serious injury that may prevent a high percentage of patients from resuming their previous physical activities. The correct identification, classification, and grading of the first MTP joint instability helps in decision-making and achieving good surgical outcomes.

Cartiva interpositional arthroplasty versus arthrodesis in the treatment of Hallux rigidus: A retrospective comparative study with mean 2 year follow up.

BACKGROUND: Hallux rigidus is a common condition characterised by first metatarsophalangeal joint (MTPJ) degeneration, pain and limited range of motion (ROM). The gold standard surgical treatment is arthrodesis, providing good pain relief, but sacrifices ROM. The Cartiva synthetic cartilage implant (SCI) has been utilised as an interpositional arthroplasty, aiming to reduce pain whilst preserving range of motion. Current evidence for Cartiva SCI is limited. The aim was to evaluate the clinical outcomes of Cartiva SCI compared to arthrodesis undertaken in our centre. METHODS: A retrospective cohort study was conducted, enrolling all adult patients who underwent primary first MTPJ SCI arthroplasty or arthrodesis for the treatment hallux rigidus. The primary outcome was a validated patient-reported outcome measure (PROM), the Manchester-Oxford Foot Questionnaire (MOXFQ). Secondary outcomes included EQ-5D, complication rates, VAS Pain and FAAM (ADL). RESULTS: Between 2017 and 2020 there were 33 cases divided into two groups (17 Cartiva SCI, 16 arthrodesis, mean age 59.0 ± 9.9 years) with a mean follow up of 2.3 years. There was no statistically significant difference in any of the MOXFQ, EQ-5D, VAS Pain or FAAM (ADL) outcome scores between the Arthrodesis and SCI groups (p > 0.05). The mean MOXFQ Index score was 7.2 ± 6.4 for the SCI group and 3.9 ± 5.8 for the Arthrodesis group at final follow up (p = 0.15). Although complications were high in both groups, the overall hallux reoperation rate was 29.4 % in the SCI cohort and 0.0 % for arthrodesis. CONCLUSION: This retrospective comparative study found no significant superiority of Cartiva SCI over arthrodesis in terms of PROMs. Due to the higher rate of further surgical intervention in the SCI cohort, we recommend arthrodesis as the preferred surgical option for hallux rigidus. LEVEL OF EVIDENCE: III.

Ultrasonography-Based Quantitative Evaluation of Second Metatarsophalangeal Joint Instability in Female Patients With Hallux Valgus.

BACKGROUND: Patients with moderate to severe hallux valgus (HV) sometimes exhibit second metatarsophalangeal (MTP) joint dislocation. Second MTP joint instability due to plantar plate (PP) injury has been suggested as one of the causes. However, there have been no reports that quantitatively evaluate this instability. This study aimed to evaluate second MTP joint instability in patients with HV without dislocation via ultrasonography and investigate its relationship with the presence of PP injury or foot form. METHODS: Between May 2018 and July 2023, symptomatic female patients with HV without any lesser toe deformity were included in this study. Second MTP joint instability was defined as the dorsal displacement ratio (DDR) of the passively subluxated proximal phalangeal articular surface on the metatarsal head articular surface. The presence of PP injury was assessed using ultrasonography. Foot "form" was determined by measuring standard foot bony angles on weight-bearing foot-ankle radiographs. The relationship between DDR or PP injury and radiographic measurements was investigated. RESULTS: Sixty-four patients (100 feet) were included. The average DDR of the second MTP joint in patients with HV without dislocation was 35.7%. There was an increase in the probability of PP injury, above a cutoff DDR value r of 35.4% (area under the curve = 0.712). The sensitivity, specificity, positive predictive value, and negative predictive value for the presence of PP injury based on this cutoff level were 63.9%, 74.4%, 79.6%, and 56.9%, respectively. Metatarsalgia was reported in 21 feet (21.0%), of which 15 feet (71.4%) showed PP injury. An increase in DDR was weakly associated with increased metatarsus adductus angle and decreased second metatarsal height. CONCLUSION: In female patients with HV without second MTP dislocation, we found ultrasonographic evidence of second MTP plantar plate injury and joint instability to be a relatively common finding with a high prevalence in those with localized metatarsalgia. LEVEL OF EVIDENCE: Level II, development of diagnostic criteria based on consecutive patients.

First metatarsophalangeal joint arthroscopy: Unearthing clinical evidence - A systematic review.

PURPOSE: Arthroscopy of the first metatarsophalangeal joint (1 MTP) has gained increasing attention in the last two decades. Despite numerous studies describing the surgical technique, only a few provide clinical or radiological outcome data. This systematic review aimed to analyze studies presenting objectively measurable clinical outcomes of patients who underwent 1 MTP arthroscopy as the primary procedure, categorizing results by indication pathology. METHODS: Following PRISMA guidelines, PubMed and Cochrane databases were searched for studies reporting outcomes of primary 1 MTP arthroscopy, regardless of underlying pathology. The selected articles were thoroughly assessed to extract data regarding the demographics of included patients, pathology, preoperative and postoperative clinical and radiological outcomes, complications, and reinterventions. RESULTS: Fourteen articles, involving 405 patients (419 halluces), were included. Common indications were hallux valgus and hallux rigidus. Notably, Hallux Valgus Angle improved from 28.9° to 12.7°, and Intermetatarsal Angle improved from 13.8° to 9.2°, where reported. In hallux rigidus patients, range of motion increased from 25.15° to 71.3° post-surgery. Temporary or permanent sensory loss occurred in 3% of treated halluces, with 4.28% requiring reoperation. CONCLUSIONS: Evidence on 1 MTP arthroscopy as the primary procedure is limited. It is most effective for hallux rigidus, while in hallux valgus cases, it can achieve satisfactory angular corrections but has a relatively high recurrence and reoperation rate. Although this technique is generally safe, further research should compare it with traditional surgical approaches to provide comprehensive insights. LEVEL OF EVIDENCE: IV.

Immediate effect of hallux valgus surgery on the biomechanical behavior of the first ray.

BACKGROUND: The surgical treatment of hallux valgus (HV) deformity has been the subject of countless publications but few focus on the altered windlass mechanism or analyze the biomechanical behavior immediately after surgery. METHODS: Patients treated for HV between January and March 2023 were included. The surgery consisted of a L-reverse first metatarsal osteotomy. To analyze the windlass mechanism we record two different measurements; the isolated first metatarsophalangeal joint (MTPJ) dorsiflexion angle (IDA) and dynamic plantarization of the first metatarsal head when performing first MTPJ dorsiflexion imprinting a mark on a modeling foam. RESULTS: A total of 30 patients diagnosed with symptomatic HV were included. In all patients, a change in the IDA angle was evident, being overall statistically significant. About modeling foam imprinted mark, all measurements, in all planes of space, had a clear tendency to increase, which turned out to be statistically significant (p < 0.001). CONCLUSIONS: An altered windlass mechanism may be successfully recovered immediately after hallux valgus deformity surgery. This could be evinced by an indirect measurement analyzing the imprint of the head of the first metatarsal in a modeling foam and the IDA. LEVELS OF EVIDENCE II: None.

Reliability of an ultrasound imaging acquisition procedure for examining osteoarthritis in the first metatarsophalangeal joint.

OBJECTIVE: Given the ability of ultrasound imaging (USI) to depict tissue-specific morphological changes before the onset of pain and before the point of irreversible structural damage, USI could play a fundamental role in earlier detection and assessment of foot osteoarthritis (OA). The current guidelines require further refinement of anatomical landmarks to establish a standardized imaging procedure to improve the interpretability and reproducibility between studies evaluating the first metatarsophalangeal joint (MTPJ). The aims were to develop an USI acquisition procedure and grading system to examine OA features in the first MTPJ and to determine intra-examiner and inter-examiner reliability of a newly developed USI acquisition procedure. DESIGN: Thirty participants with first MTPJ OA confirmed radiographically with the use of the La Trobe Foot Atlas were included. An experienced sonographer applied a newly developed USI procedure to examine the following features: joint effusion, synovial hypertrophy, synovitis, joint space narrowing, osteophytes, and cartilage thickness. A semiquantitative grading system was applied to all features. A continuous measure was also examined for osteophyte size, joint space narrowing, and cartilage thickness. To determine the intra-examiner and inter-examiner reliability, an experienced radiologist and sonographer applied the developed grading system to the images acquired from two imaging sessions. Intra-examiner and inter-examiner reliability were calculated using intraclass correlation coefficients (ICCs). RESULTS: ICCs for intra-examiner between session reliability ranged from 0.58 to 0.92 for semiquantitative grading and 0.39 to 0.94 for continuous measures. Joint effusion and osteophytes achieved the highest intra-examiner reliability (ICC = 0.78-0.94). ICCs for session one inter-examiner reliability ranged from 0.61 to 1.0 for semiquantitative grading; all continuous measures had an ICC of 1. ICCs for session two inter-examiner reliability ranged from 0.55 to 1.0 for semiquantitative grading and 0.9 to 0.97 for continuous measures. Inter-examiner reliability was good for grading joint effusion (ICC = 0.55-0.62) and was excellent for all other USI features (ICC = 0.77-1.0). CONCLUSION: The USI acquisition procedure and grading system are reliable in evaluating first MTPJ OA features in participants with radiologically confirmed OA. The study will inform the methodological development of an ultrasound atlas for grading the degree of osteoarthritic change in the first MTPJ.

Case Report: Portable handheld ultrasound facilitates intra-articular injections in articular foot pathologies.

Background: Intra-articular injections are commonly used to manage joint pathologies, including osteoarthritis. While conventional ultrasound (US) guidance has generally improved intra-articular injection accuracy, forefoot and midfoot joint interventions are still often performed without imaging guidance. This pilot study aims to evaluate the efficacy of office-based, portable ultrasound (P-US) guided intra-articular injections for forefoot and midfoot joint pain caused by various degenerative pathologies. Methods: A retrospective analysis was conducted on a series of consecutive patients who underwent P-US guided intra-articular injections following a chief complaint of forefoot or midfoot joint pain. Patients reported their pain levels using the Visual Analog Scale (VAS) pre-injection and at 3 months follow-up. The procedure was performed by an experienced foot and ankle surgeon using a linear array transducer for guidance, and a 25-gauge needle was used to inject a combination of 2 cc 1% lidocaine and 12 cc of Kenalog (40 mg/ml). Complications and pain scores were analyzed using a paired t-test and p < 0.05 was considered significant. Results: We included 16 patients, 31% male and 69% female with a mean age (±SD) of 61.31 (±12.04) years. None of the patients experienced immediate complications following the intervention. The mean pre-injection VAS score was significantly reduced from 5.21 (±2.04) to a mean of 0.50 (±1.32) at 3 months follow-up (P < 0.001). Thirteen patients reported complete resolution of pain at the 3-month follow-up. No adverse events were reported throughout the duration of the study. Conclusion: This pilot study suggests P-US-guided intra-articular injections offer a safe and effective method for managing forefoot and midfoot joint pain caused by various arthritic pathologies. Further research is warranted to establish the long-term efficacy and comparative effectiveness of P-US-guided injections in larger patient cohorts as compared to non-image guided injections.

Cross-sectional study of the prevalence of hyperextension of the first metatarsophalangeal joint and its relationship to onycholysis in women with hallux valgus.

BACKGROUND: Hallux Valgus (HV) deformity is associated with misalignment in the sagittal plane that affects the first toe. However, the repercussions of the first toe hyperextension in HV have been scarcely considered. The purpose of this study was to provide evidence of the association between first-toe hyperextension and the risk of first toenail onycholysis in HV. METHODS: A total of 248 HV from 129 females were included. The extension of 1st MTP joint was measured while the patient was in the neutral position of the hallux using a two-branch goniometer. The classification of the HV severity stage was determined by the Manchester visual scale, and the height of the first toe in the standing position was measured using a digital meter. An interview and clinical examination were performed to collect information on the presence of onycholysis of the first toe. RESULTS: Of the 248 HV studied, 100 (40.3%) had onycholysis. A neutral extension > 30 degrees was noted in 110 (44.3%) HV. The incidence of onycholysis was higher in HV type C than in type B (p = 0.044). The probability of suffering onycholysis in the right foot was 2.3 times greater when the neutral position was higher than 30 degrees (OR = 2.3; p = 0.004). However, this was not observed in the left foot (p = 0.171). Onycholysis was more frequent in HV with more than 2 cm height of the first toe (p < 0.001). For both feet, the probability of suffering onycholysis was greater for each unit increase in hallux height (right foot OR = 9.0402, p = 0.005; left foot OR = 7.6633, p = 0.010). CONCLUSIONS: The incidence of onycholysis appears to be significantly associated with HV showing more than 30º extension, and more than 2 cm height of the first toe. Height and hyperextension of the first toe together with first toenail pathology should be mandatory in the evaluation of HV.