Short-Term Outcomes of Arthroscopic Treatment of Freiberg Disease.

BACKGROUND: Surgical treatment for Freiberg disease (also known as avascular necrosis of the metatarsal head) has not been completely defined. This retrospective study evaluated short-term outcomes after arthroscopic treatment of Freiberg disease. METHODS: From 2015 to 2019, 13 patients (15 feet) diagnosed as having Freiberg disease were enrolled for arthroscopic surgery. Feet were divided based on the Smillie classification system (two with stage I, eight with stage II, three with stage III, one with stage IV, and one with stage V). Arthroscopic interventions, including synovectomy, debridement, chondroplasty, microfracture, and loose body removal, were performed without considering the Smillie classification stage. Radiologic outcomes were evaluated by radiography (preoperatively and 3, 6, and 12 months postoperatively) and magnetic resonance imaging (preoperatively and 12 months postoperatively). Clinical outcomes were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) lesser metatarsophalangeal (MTP)-interphalangeal score and the visual analog scale (VAS) score. The MTP joint range of motion was measured using a goniometer preoperatively and postoperatively. RESULTS: Radiologic studies showed no evidence of osteonecrosis progression in postoperative 12-month radiographs of any patients. Postoperative 12-month magnetic resonance images showed reduction of bone marrow edema, irregularity of subchondral bone, and cartilage defects in all patients. Significant improvements in AOFAS and VAS scores occurred at all postoperative time points compared with preoperative scores (P = .001). The MTP joint range of motion also showed improvement at last follow-up (P = .001). CONCLUSIONS: Arthroscopic surgery for Freiberg disease showed excellent clinical outcomes, MTP joint range of motion, and short-term outcomes regardless of stage (Smillie classification) in radiologic evaluation.

Cone beam computed tomography and cross-sectional anatomy of the region of the fetlock in the horse (Equus caballus).

This study aimed to delineate the detailed anatomy of the metacarpophalangeal (MCP) and metatarsophalangeal (MTP) joints in healthy horses using cone beam computed tomography (CBCT). The fetlock region of 15 cadaveric forelimbs and 14 cadaveric hindlimbs from nine adult horses without orthopaedic disease underwent CBCT scanning. Additionally, arthrography CBCT scans were conducted following intra-articular injection of a radiopaque contrast medium containing blue epoxy resin dye. Subsequently, limbs were frozen and sectioned to visualize anatomical structures in sectional planes corresponding to selected CBCT images. CBCT proved suitable for detailed visualization of the bony components of the fetlock region. Furthermore, the common digital extensor tendon, superficial and deep digital flexor tendons, suspensory ligament, and straight and oblique sesamoidean ligaments were identifiable on CBCT images. However, certain ligaments, such as the collateral sesamoidean ligaments and intersesamoidean ligaments, were not clearly identified. The hyaline cartilage of the MCP and MTP joint facets was assessable on the post-contrast sequence. In cases where a radiographic or ultrasound examination cannot provide a definitive diagnosis and determine the extent of disease, CBCT can provide additional valuable data on the equine MCP and MTP joint. The images obtained in this study can serve as a reference for CBCT examination of the equine MCP and MTP joint.

Hallux Rigidus: Anatomy and Pathology.

Hallux rigidus is a common degenerative condition of the hallux metatarsophalangeal joint (MTPJ) characterized by pain, swelling, stiffness, and limited range of motion with characteristic corresponding clinical, physical examination, and radiographic findings. Many historical risks factors including trauma and family history and patient factors including hallux valgus interphalangeus and inflammatory arthropathies have a well-substantiated etiologic role in the disease process. The purpose of this section is to review the normal and pathologic anatomy and biomechanics of the hallux MTPJ while providing an overview of the current understanding and remain debate regarding the disease process.

Interpositional Arthroplasty for Hallux Rigidus: Surgical Technique and Outcomes Discussion.

Interpositional arthroplasty for the treatment of hallux rigidus (HR) involves resection of the diseased joint surface and placement of spacer material within the joint to preserve length at the metatarsophalangeal joint while still allowing for range of motion. The majority of studies available in the literature have focused on capsular interpositional arthroplasty, revealing generally positive outcomes. Other forms of interpositional arthroplasty are less supported by long-term follow-up and large sample sizes. Moreover, there exists substantial heterogeneity in the studies evaluating interpositional arthroplasty. Despite the limitations of the current data, interpositional arthroplasty seems to be a viable treatment option for HR.

Minimally Invasive Cheilectomy for Hallux Rigidus.

Hallux metatarsophalangeal joint cheilectomy is a joint-sparing technique that involves resection of the dorsal metatarsal head osteophytes; this may be achieved through minimally invasive and arthroscopic techniques. General indications for minimally invasive surgery (MIS) cheilectomy are mild-to-moderate hallux rigidus (Grades I-II) with symptomatic dorsal osteophytes causing dorsal impingement and/or shoe wear irritation in those who have failed extensive nonoperative management. The literature confirms equivalent outcomes to open cheilectomy; however, it is somewhat inconsistent regarding superiority. The theoretic benefits of MIS cheilectomy include better cosmesis, reduced wound complications, less soft tissue disruption, and faster recovery.

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.

Cartiva: A Review of the Best Evidence.

The Cartiva implant is a synthetic polyvinyl alcohol hydrogel cartilage substitute that is used as a treatment of first metatarsophalangeal joint arthritis. The implant was designed to relieve the pain associated with hallux rigidus while preserving or restoring range of motion. A summary of outcomes, reasons for these outcomes, and technique pearls will be reviewed here. Seminal articles and current evidence are all included in this article. The aim is for the surgeon to understand all the literature, allowing the surgeon to counsel their patients appropriately, optimize patient selection and to deal with complications.

Arthrodesis for Hallux Rigidus.

First metatarsophalangeal (MTP) joint fusion, or arthrodesis, has been a cornerstone treatment for advanced joint degeneration since the 1950s, benefiting not only older patients but also younger individuals. The procedure boasts favorable long-term outcomes and a low rate of revision when fusion is successful. However, complications such as interphalangeal arthritis may occur, and nonunion or malunion can necessitate revision. While the first MTP fusion provides significant relief, its applicability varies, underscoring the need for careful patient selection.

Effect of Prior Cheilectomy on Outcomes of First Metatarsophalangeal Joint Fusion.

Cheilectomy, a joint-conserving procedure, is often a first-line choice for treating early stages of hallux rigidus. Recent evidence has revealed its efficacy in treating more advanced stages. However, when degeneration is profound, first metatarsophalangeal (MTP) fusion remains the most appropriate strategy. Nevertheless, it is common for surgeons to proceed initially with cheilectomy, reserving joint fusion for subsequent considerations if cheilectomy fails. This article will explore the relationship between the 2 procedures and evaluate the research surrounding the effect of prior cheilectomy on first MTP joint arthrodesis.

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.

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.

[Long-term clinical and radiological results of metatarsophalangeal resection arthroplasty in patients with large forefoot deformities]. / Resultados clínicos y radiológicos a largo plazo de la artroplastía de resección metatarsofalángica en pacientes con grandes deformidades del antepié.

INTRODUCTION: metatarsophalangeal resection arthroplasty is considered a salvage surgical procedure able to improve the quality of life of patients with major forefoot deformities. MATERIAL AND METHODS: a retrospective observational study of 31 patients (36 feet) with major forefoot deformities operated at our institution was performed. Thirty two feet required additional surgery involving the first ray, most of them (72.2%) through MTP joint fusion. The mean follow-up period was 10.3 ± 4.6 years. Most patients were women (87.1%), the mean age was 74.2 ± 11.5 years. RESULTS: at the final follow-up, mean AOFAS score was 77.9 ± 10.2 points and mean MOxFQ score was 18.3 ± 8.3 points. Visual analog scale (VAS) for pain improved significantly from 7.5 ± 1.2 points to 3.4 ± 2.1 points on average. Good clinical results were also reported on ability to put on shoes comfortably. The mean resection arthroplasty spaces at the end of the study were 1.3, 1.8, 2.5 and 4.4 mm, for second to fifth rays, respectively. The mean sizes of remodeling osteophytes at the end of the study were 1.6, 1.4, 1.1 and 0.7 mm, respectively. Significant improvement was also achieved in the hallux valgus angle (HVA) and intermetatarsal angle (IMA) at the end of the study. CONCLUSION: in our experience, metatarsophalangeal resection arthroplasty continues to be a valid choice in patients with major forefoot deformities, with satisfactory long-term clinical and radiographic results.

INTRODUCCIÓN: la artroplastía de resección metatarsofalángica se considera un procedimiento quirúrgico de salvamento capaz de mejorar la calidad de vida de pacientes con deformidades importantes en el antepié. MATERIAL Y MÉTODOS: se realizó un estudio observacional retrospectivo de 31 pacientes (36 pies) con deformidades importantes en el antepié operados en nuestra institución. Treinta y dos pies requirieron cirugía adicional que involucró el primer metatarsiano, la mayoría de ellos (72.2%) a través de la fusión de la articulación metatarsofalángica. El período de seguimiento promedio fue 10.3 ± 4.6 años. La mayoría de los pacientes fueron mujeres (87.1%), con una edad promedio de 74.2 ± 11.5 años. RESULTADOS: en la última visita de seguimiento, la puntuación AOFAS promedio fue de 77.9 ± 10.2 puntos y la puntuación MOxFQ promedio fue de 18.3 ± 8.3 puntos. La escala visual analógica (EVA) para el dolor mejoró significativamente, pasando de 7.5 ± 1.2 puntos a 3.4 ± 2.1 puntos de media. También se constataron buenos resultados clínicos en cuanto a la capacidad de calzarse con comodidad. Los espacios de resección promedio al final del estudio fueron 1.3, 1.8, 2.5 y 4.4 mm para el segundo al quinto radio, respectivamente. Los tamaños promedio de los osteofitos por remodelación al final del estudio fueron de 1.6, 1.4, 1.1 y 0.7 mm, respectivamente. También se logró una mejora significativa en el ángulo de hallux valgus (AHV) y en el ángulo intermetatarsiano (IMA) al final del estudio. CONCLUSIÓN: en nuestra experiencia, la artroplastía de resección metatarsofalángica sigue siendo una opción válida en pacientes con deformidades graves del antepié, con resultados clínicos y radiográficos satisfactorios a largo plazo.

Comparative analysis of mechanical conditions in bone union following first metatarsophalangeal joint arthrodesis with varied locking plate positions: A finite element analysis.

BACKGROUND: First metatarsophalangeal joint arthrodesis is a typical medical treatment performed in cases of arthritis or joint deformity. The gold standard for this procedure is arthrodesis stabilisation with the dorsally positioned plate. However, according to the authors' previous studies, medially positioned plate provides greater bending stiffness. It is worth to compare the mechanical conditions for bone formation in the fracture callus for both placements of the locking plate. METHODS: Two finite element models of the first metatarsophalangeal joint with the dorsally and medially positioned plate were defined in the Abaqus software to simulate differentiation of the fracture callus. A simplified load application, i.e. one single step per each day and the diffusion of the mesenchymal stem cells into the fracture region were assumed in an iterative hardening process. The changes of the mesenchymal stem cells into different phenotypes during the callus stiffening were governed by the octahedral shear strain and interstitial fluid velocity according to Prendergast mechanoregulation theory. Basing on the obtained results the progress of the cartilage and bone tissues formation and their distribution within the callus were compared between two models. FINDINGS: The obtained results suggest that after 6 weeks of simulation the healing progress is in general comparable for both plates. However, earlier closing of external callus was observed for the medially positioned plate which had greater vertical bending stiffness. This process enables faster internal callus hardening and promotes symmetrical bridging.

Effectiveness of footwear and foot orthoses in reducing medial metatarsophalangeal joint pressure in women with hallux valgus.

BACKGROUND: Hallux valgus is a common condition where the subluxation of the first metatarsophalangeal joint and lateral deviation of the hallux at the interphalangeal joint creates difficulty with footwear fit. Footwear and foot orthoses are commonly prescribed nonsurgical treatments for hallux valgus. RESEARCH QUESTION: Do extra-width footwear and foot orthoses influence peak pressure at the medial aspect of the metatarsophalangeal and interphalangeal joints in women with hallux valgus? METHODS: Community-dwelling women with symptomatic hallux valgus underwent gait testing when wearing their own shoes and when wearing extra-width footwear fitted with three-quarter length, arch-contouring prefabricated foot orthoses. Peak pressure (kPa) on the medial aspect of the metatarsophalangeal and medial interphalangeal joints and on the plantar surface of the foot (hallux, lesser toes, metatarsophalangeal joint 1, metatarsophalangeal joints 2-5, midfoot and heel) were measured using the novel pedar®-X system with the pedar® pad and pedar® insole, respectively (Novel, GmbH, Munich, Germany). Paired samples t-tests were used to calculate the differences between the two conditions, and the magnitude of observed differences was calculated using Cohen's d. RESULTS: We tested 28 participants (aged 44-80 years, mean 60.7, standard deviation 10.7). Compared to their own footwear, wearing the intervention footwear and orthoses was associated with a statistically significant decrease in pressure on the medial aspect of the metatarsophalangeal joint (58.3 ± 32.8 versus 42.6 ± 32.8, p=0.026, d=0.49), increased pressure under the midfoot (70.7 ± 25.7 versus 78.7 ± 23.6, p=0.029, d=0.33) and decreased pressure underneath the heel (137.3 ± 39.0 versus 121.3 ± 34.8, p=0.019, d=0.45). SIGNIFICANCE: The intervention footwear and orthoses significantly decreased peak pressure on the medial aspect of the first metatarsophalangeal joint but had no significant effect on the interphalangeal joint. Further studies are required to determine whether these changes are associated with improvements in symptoms associated with hallux valgus.

Postoperative Maintenance of Sagittal Plane Positioning of the First Metatarsophalangeal Joint After Arthrodesis with an Isolated Dorsal Plate Construct: A Retrospective Review of 43 Feet.

BACKGROUND: First metatarsophalangeal joint arthrodesis with isolated dorsal plating without a lag screw and without a compressive mechanism incorporated into the plate is not well studied. Although surface area for bony fusion is increased, there is concern for lower fusion rates and progressive loss of sagittal plane positioning. We present fusion rates and progressive sagittal plane deviation with isolated dorsal plate fixation. METHODS: A retrospective review was performed of 41 patients (43 feet) who underwent first metatarsophalangeal joint arthrodesis with isolated dorsal plate fixation. Patients were excluded if another form of fixation was used, if there was a compressive feature to the dorsal plate, or if a lag screw was used. Preoperative, immediate postoperative, and final postoperative radiographs were reviewed to assess radiographic alignment and fusion about the first metatarsophalangeal joint. Specific attention was placed on hallux dorsiflexion in relation to the first metatarsal. Statistical significance was set at P ≤ .05 a priori. RESULTS: Patients were followed for an average of 55.7 weeks. Overall union rate was 97.62%. The average time to union was 42.55 days. Reoperation rate was 4.65%, with one patient requiring revisional arthrodesis with a lag screw construct. Hallux abduction and first-second intermetatarsal angle correction reached significance (P < .00001). Hallux dorsiflexion increased by 1.05° between initial postoperative and final postoperative radiographs (P = .542). CONCLUSIONS: Although fusion rates and progressive loss of sagittal plane position have been concerns for first metatarsophalangeal joint arthrodesis with an isolated dorsal plate construct, these results suggest this to be a stable construct without loss of positioning over time.

Limb salvage and systemic management of gouty tophi: Case series.

INTRODUCTION: Gout is a chronic disease characterized by deposition of monosodium urate crystals. Tophi develop in some individuals with untreated or uncontrolled gout, which leads to ulcerations, cosmetic problems, mechanical obstruction of joint movement, joint damage and musculoskeletal disability. Currently, the treatment of gouty tophi is controversial and challenging. Both surgical and internal medical treatments have limitations and require further exploration in clinical practice. PATIENT CONCERNS: In Case 1, we treated a patient with severe infection of diabetic foot ulcers with concomitant multiple gouty tophi in the same limb. A systematic management strategy was formulated to close the wound and save the limb. The ulcers healed successfully after half a year. In Case 2, a giant gouty tophi located in the first metatarsophalangeal joint of the left foot was removed by surgical treatment and vancomycin-loaded bone cement implantation. In Case 3, we present a case of gouty tophi that was resolved by standardized systemic medical management. DIAGNOSIS: Three patients were all diagnosed with gout accompanied by gouty deposition, although there were other different comorbidities. INTERVENTIONS: In case 1, we used debridement to gradually remove gouty tophi. In case 2, the giant gouty tophi was removed by surgical operation. In case 3, the gouty tophi disappeared after standardized treatment with medicine, diet and lifestyle management. OUTCOMES: Three patients underwent different treatment therapies to remove gouty tophi based on their specific conditions. LESSONS: We explored effective interventions for tophi in gout by surgical or other interventions in combination with pharmacotherapy.

First Metatarsal Headphones-Like Lesion: A Case of Unreducible Sesamoid Complex Dislocation.

CASE: A 34-year-old woman sustained a direct trauma to the left hallux during a fall. Radiographs showed a dorsal dislocation of the first metatarsophalangeal joint and a wide separation of sesamoid complex. Closed reduction was tried: postreduction radiographs displayed reduction of first metatarsophalangeal joint and a complete sesamoid complex dislocation. The patient was scheduled for surgery. Through a medial approach, open reduction together with plantar structures release and repair were performed. Functional and radiographic outcomes were satisfactory at the last follow-up. CONCLUSION: In case of a "headphones-like lesion" surgery is required, together with plantar structures repair.

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.

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.