Subungual Osteochondroma of the Great Toe: A Case Report.

Bony outgrowths of the distal phalanx of the great toe have been described in the literature but rarely. These subungual bony outgrowths can be caused by subungual exostosis or subungual osteochondromas. Both of these abnormalities are bony outgrowths with differences in the cartilage cap wherein the exostoses have fibrocartilage, and osteochondromas have hyaline cartilage. The subungual exostosis and osteochondroma that are protruding present symptoms of pain, redness, and deformed nail bed, whereas the nonprotruding osteochondromas have only a lump as the presenting symptom. In both conditions, excision of the lesion and curettage of the base helps prevent a recurrence. Curettage at the end of the excision of the bony outgrowth is required to avoid recurrence. After excision, the specimen should be sent for histopathologic examination to differentiate between the exostosis and osteochondromas, which are underreported in subungual locations, and to rule out malignant transformation. We present a 13-year-old girl with an isolated subungual nonprotruding exostosis of the great toe that was treated by excisional biopsy. The histopathologic examination confirmed it as osteochondroma, which is underreported.

Rate and Location of Reulceration and Reamputation After Partial First-Ray Amputation versus Hallux Amputation in Diabetic and Nondiabetic Populations.

BACKGROUND: We sought to determine the rates of reulceration and reamputation in individuals who underwent partial first-ray amputations versus hallux amputations in diabetic and nondiabetic populations. METHODS: Eighty-four amputations were reviewed in a retrospective fashion. A retrospective medical record review was performed to determine patients who underwent a hallux amputation, both partial and complete, and patients who underwent a partial first-ray amputation. Only patients from 2007 to 2019 were reviewed. The reulceration rate of hallux amputations was 61% compared with a partial first-ray amputation reulceration rate of 74%. RESULTS: The reamputation rate of hallux amputation versus partial first-ray amputation was 43% versus 51%. At final follow-up, it was statistically significant that patients who underwent hallux amputation were more likely to be healed than those who underwent partial first-ray amputation, regardless of reulceration or reamputation. In addition, patients who underwent hallux amputation went on to digital amputation, and those who underwent partial first-ray amputation went on to transmetatarsal amputation. CONCLUSIONS: Comparing partial first-ray amputation to hallux amputation, hallux amputation patients are more prone to subsequent digital ulceration. Patients who initially undergo hallux amputation have variable subsequent amputations, often digital. Reulceration primarily occurs at the incision site for partial first-ray amputations, with a higher likelihood of subsequent transmetatarsal amputation. Patients with a medical history of diabetes and staged procedures are more likely to receive partial first-ray amputations. However, hallux amputation patients have a lower risk of reulceration and reamputation, regardless of subsequent events. These findings underscore the importance of discussing risks and preventive measures with patients undergoing such amputations, emphasizing postoperative examinations for specific areas of concern. Hallux amputation appears to offer greater protection against reulceration and reamputation for both diabetic and nondiabetic populations.

Proximal toe wrap-around: a coverage technique for circumferential skin defects of the fingers.

Circumferential skin defects of the fingers are a technical challenge. Although rare, their management should respect tissue organization and functional abilities. We report two cases of circumferential skin defect. Management used individually tailored "wrap-around" flaps taken from the hallux. The sample concerned the proximal cutaneous sheath of the first toe and the neurovascular pedicle of the first inter-metatarsal space. Nail and toe pad were spared. Both cases had complex circumferential skin defect of the finger, involving the neuro-vascular pedicle. Postoperative results were favorable, without functional limitation. The wrap-around technique provided skin coverage and also neurovascular pedicle reconstruction. Donor site damage was limited, with no functional consequences. This technique is a valuable option for management of circumferential skin defect of the finger.

Combined Great Toe Dorsal Nail-Skin Flap and Medial Plantar Flap for Reconstruction of Degloved Finger Loss.

BACKGROUND: Historically, the degloved finger with the total loss of nails and skin has been resurfaced in two stages. Furthermore, proximal finger amputation requires an additional bone-tendon graft and an expanded great toe wraparound flap transfer for better outcomes. This article recommends a novel strategy to address these problems in a single stage using a dorsal nail-skin flap and medial plantar artery perforator flap. METHODS: From March of 2015 to June of 2018, nine procedures were performed to resurface with skin loss to the metacarpophalangeal joint level, and three amputated fingers were reconstructed with an extra bone-joint-tendon graft simultaneously. The dorsal great toe donor was covered with a thin groin flap, and the medial plantar site was covered with a full-thickness skin graft. A standardized assessment of outcome in terms of sensory, functional, and aesthetic performance was completed. RESULTS: All flaps survived. The contour and length of the reconstructed digits were comparable with the contralateral finger. The mean static two-point discrimination was 11.0 mm (range, 9.0 to 14.0 mm). The average score of the Disabilities of the Arm, Shoulder, and Hand questionnaire and Michigan Hand Outcomes Questionnaire were 2.5 (range, 0 to 5) and 90.1 (range, 82 to 96), respectively. The mean Foot and Ankle Disability Index score was 95.6 (range, 93 to 99). At the last follow-up, the functional and aesthetic outcomes, and the restored sensation, were satisfactory for all fingers. CONCLUSION: This strategy may provide an alternative for selected patients seeking cosmetic resurfacing and functional reconstruction, preserving a weight-bearing plantar area with less morbidity. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Hallux Valgus: The Influence of Intersesamoid Crista's Osteoarthritis on Frontal Plane Pronation.

A frontal plane metatarsal rotational (pronation) has been documented in a high percentage of hallux valgus patients. Pathoanatomical concepts leading to pronation are still debated. Nevertheless, there is no consensus on how to measure this component of the deformity. The aim of the present study was to find potential associations between sesamoid's crista osteoarthritis and the frontal plane deformity in HV cases. Our study showed a moderate correlation between the crista's OA and the intermetatarsal angle (IMA), the hallux valgus angle (HVA) and the alpha angle. In severe hallux vulgus deformed specimens, with an eroded intersesamoid crista, frontal plane pronation was not as prevalent nor severe as in those without osteoarthritic degeneration. Severe hallux valgus cases with a completely eroded crista, showed lower pronation, and higher IMA, when compared to specimens with a preserved anatomy. This brings to light the intersesamoid crista's unique function in retaining the IMA. Understanding the role the frontal plane plays in hallux valgus' biomechanics and in its radiographic appearance is vital to change the current paradigm.

Great Toe Interphalangeal Fusion for Hallux Valgus Interphalangeus Deformity in Young Patients.

OBJECTIVES: The purposes of this study were to examine indications, radiographic outcomes, and clinical complications for primary arthrodesis of the great toe interphalangeal (IP) joint in young patients. BACKGROUND: Hallux valgus interphalangeus deformity of the great toe is uncommon in the pediatric population and often requires fusion of the IP joint. METHODS: A retrospective review of patients, ages 8 to 19 years, who underwent operative fusion of the great toe IP joint, and had >1 year radiographic follow-up was performed. Medical records and radiographs were reviewed to determine indications for surgery, concomitant procedures, success of fusion, complications, and need for revision procedures or elective hardware removal. Differences between pre and postradiographic outcomes for the hallux valgus angle, IP angle, and intermetatarsal angle were analyzed. RESULTS: Twenty-seven patients (31 feet) were included in the analyses. The average age at fusion surgery was 14.9 years (SD ± 2.3) with a mean follow-up visit of 35.2 months. The most common indications for fusion of the great toe IP joint were pain and deformity. Kirschner wire fixation was utilized in 7 cases, with the remaining 24 cases fixed with a single retrograde cannulated screw. Fifty-five concomitant toe and foot procedures were performed in 21 feet (68%) to address additional foot and toe deformity. Successful fusion occurred in 30 of 31 toes after the primary fusion. Patient satisfaction with the toe position and diminished pain were high (94.1%). Significant improvement was noted in the measure of the IP angle ( P < 0.001), with minimal clinical change in the hallux valgus angle ( P = 0.24) or the intermetatarsal angle ( P = 0.03). CONCLUSIONS: Hallux valgus interphalangeus of the great toe was successfully managed with the fusion of the IP joint. Single screw fixation or the use of Kirschner wires led to similar outcomes. Hardware-related issues with the use of screws were the most common adverse outcome. Patients should be made aware of the possible need for hardware removal after fusion utilizing screw fixation. LEVEL OF EVIDENCE: Level IV-a retrospective case series.

[Case report: Great toe dorsal defect reconstruction by cross-toe flap]. / Cas clinique : reconstruction d'une perte de substance de la face dorsale de l'hallux par lambeau cross-toe.

Reconstruction of hallux soft-tissue defects is essential for the locomotor function. Some regional flaps are available and have to be preferred in case of small defect. Here, we present the case of a patient treated by a cross-toe flap in order to cover an exposed hallux proximal interphalangeal joint, after an open fracture. The functional outcome of this reliable and easy flap was very satisfying, with quick wound healing and resumption walk.

Treatment of Dynamic Claw Toe Deformity Through Lengthening of the Flexor Tendons of the Hallux and Toes at the Midfoot Level.

The claw toe deformity is characterized by the flexion of interphalangeal joints (IPJs) with hyperextension of the metatarsophalangeal (MTP) joint. It can be flexible and reducible or rigid and irreducible, or dynamic. The most common cause of dynamic claw toes is a neurological disorder, like sequelae of an ischemic contracture of the muscle belly after a compartment syndrome. Most of the surgical techniques require multiple procedures and may be associated with complications such as toe stiffness, persisting metatarsalgia, and toe malalignment. The aim of this study is to present an option for the surgical treatment of the dynamic claw toe deformity, by simultaneous tenodesis and lengthening of the flexor hallucis longus (FHL) and flexor digitorum longus (FDL) tendons at Henry's knot through a single midfoot incision.Levels of Evidence: V; Therapeutic Study; Expert Opinion.

A 28-Year-Old Woman with Down Syndrome, Congenital Heart Disease, and a History of Knee Surgery and Plantar Fasciitis, with Hallux Abducto Valgus (Bunion) and Lapiplasty Three-Dimensional Correction Surgery.

BACKGROUND Tarsometatarsal joint (TMJ) arthrodesis is common method used for correcting hallux abductus valgus (HAV). Its popularity has grown due to studies revealing HAV's triplanar deformity with frontal plane rotation. This case report presents a 28-year-old woman with Down syndrome, congenital heart disease, and a history of knee surgery and plantar fasciitis, with severe HAV deformity and flexible valgus flatfoot associated with ligamentous hyperlaxity. CASE REPORT Examination revealed severe foot deformities, and radiographic studies confirmed the condition. A surgical intervention was planned, and the patient's cardiologist confirmed she was fit for the procedure. The modified Lapidus technique with frontal plane rotational correction included realigning the metatarsal joint, resecting spurs, osteosynthesis material, and arthrosis in the sinus tarsi. After surgery, the patient underwent a recovery period without support for 8 weeks and received appropriate medical care. Radiographs showed successful alignment, and the patient gradually resumed her daily activities. The patient had an uneventful recovery, and postoperative radiographs showed good alignment in all planes. CONCLUSIONS The hyperlaxity associated with Down syndrome makes the incidence of HAV more frequent, and TMJ fusion is preferable to correction by osteotomy. The modified Lapidus technique with frontal plane rotational correction could be a good technique to achieve satisfactory correction in patients with severe HAV deformity and flexible valgus flatfoot associated with ligamentous hyperlaxity. TMJ fusion is indicated when severe or recurrent rotational component is observed in X-rays.

Clinical outcomes of selective plantar fascia release for hallux interphalangeal joint ulcers.

BACKGROUND: Plantar hallux IPJ ulcers are common and challenging to manage, with many available treatments. One newer technique called SPFR has been used in the management of plantar forefoot ulcers. OBJECTIVE: This case series reports the clinical results of SPFR for treatment of strictly plantar hallux IPJ ulcers. MATERIALS AND METHODS: A retrospective chart review was conducted on patients that underwent SPFR procedure by a single foot and ankle surgeon from 2018 to 2023. The primary study outcome was to identify the rate and time of healing associated with SPFR for hallux IPJ ulcers. Only the initial surgery was evaluated for time of healing for the ulcer, healing rate, and complications. Subsequent surgeries were reviewed as well. Patient charts were further reviewed to determine the presence or absence of a postoperative complication. RESULTS: A total of 17 feet from 17 patients were studied. The hallux IPJ ulcers healed in an average of 3.0 months. The average follow-up time was 26.9 months. Fifteen patients (88.2%) healed after the SPFR procedure. Five patients (29.4%) developed transfer lesions, and 7 patients (41.2%) developed postoperative complications. CONCLUSIONS: The authors believe that SPFR can be utilized in the treatment of hallux IPJ ulcers if both surgeons and patients are aware of the potential complications and limitations of this procedure. Further research is warranted to evaluate the efficacy and reproducibility of these results.

Severe Soft Tissue Loss on Dorsum of the Foot with Irreparable Hallucis Extensors: An Orthoplastic Reconstruction Case Report.

CASE: A motorcycle accident resulted in severe soft tissue loss on the foot's dorsum with irreparable hallucis extensors, with exposure of the first metatarsal and hallux. An arthrodesis of the hallux interphalangeal joint, a transfer of the second toe's extensor digitorum longus, and an anterolateral thigh free flap were performed simultaneously. The patient obtained a fair result and could wear regular shoes. DISCUSSION: This is the first report describing this orthoplastic reconstructive option in these complex injuries. It replenished both hallux extensor tendons and soft tissue coverage losses without severely compromising the foot's contour, recreating anatomy and function.

Multiple factors contributing to the metatarsal head eversion in hallux valgus deformity. A prospective study using weight-bearing CT.

PURPOSE: Recently first tarsometatarsal arthrodesis for hallux abducto valgus (HAV) has been advocated as the sole procedure to correct the multiplanar components of the deformity. However, recent debate suggests other factors such as rearfoot pronation and metatarsal torsion affect frontal plane metatarsal eversion and sesamoid positioning. Using weight-bearing CT, 12 feet (12 subjects) with HAV deformities were placed in positions of maximum rearfoot pronation and supination in order to study the effects on metatarsal eversion, sesamoid rotation/displacement, and secondarily the influence of first metatarsal torsion. Sesamoid displacement was quantified by the novel use of the sesamoid displacement angle. PRINCIPLE RESULTS: Although first metatarsal eversion was nearly double in the pronated versus supinated foot, the difference was not statistically significant. Therefore, the bulk of first metatarsal eversion was not secondary to rearfoot eversion. Conversely, a significant positive correlation was found between metatarsal torsion and metatarsal head eversion angles in both supinated and pronated foot positions, with the strongest correlation with rearfoot pronation. Finally, significant increases in sesamoid displacement angles were noted with pronation. MAJOR CONCLUSIONS: The findings of the present study support the contention that multiple factors are associated with frontal plane first metatarsal eversion and sesamoid displacement. Weight-bearing CT scanning can be used to effectively evaluate the frontal plane components in HAV deformities. The sesamoid displacement angle appears to be a useful adjunct to evaluating the hallucal sesamoids. For surgical correction of the deformity, consideration should be given to pre-operative weight-bearing CT evaluation of the foot. This can illuminate the effects of rearfoot/medial column pronation and the potential influence of metatarsal torsion on the frontal plane components of this triplane deformity. In this way the potential for post-operative HAV recurrence can be minimized.

Outcomes After Hallux Interphalangeal Joint Arthrodesis.

BACKGROUND: Hallux interphalangeal joint arthrodesis (HIPJA) is indicated for a variety of pathologies. Despite high nonunion rates, techniques remain unchanged. The aim of this study is to examine nonunion and complication rates and describe risk factors for treatment failure. METHODS: A query of an institutional database was performed to identify all patients undergoing HIPJA procedure over a 10-year period. Records were reviewed to the procedure, evaluate patient factors, indications, and radiographic/clinical arthrodesis. Radiographic union was defined as 2 cortical continuations or bridging at the arthrodesis site, absence of hardware failure, and the absence of lytic gapping of the arthrodesis. Clinical fibrous union was defined as radiographic nonunion with painless toe range of motion and physical examination consistent with fusion across the interphalangeal joint. RESULTS: Two hundred twenty-seven primary HIPJA procedures were identified. Our cohort demonstrated a 25.5% nonunion rate (58/227) and 21.1% reoperation rate (48/227). Patients with diabetes were at higher risk for nonunion (P = .014), but no significant differences were identified based on smoking status or diagnosis of inflammatory arthritis. No difference was seen between implant groups: single screw, multiple screws, screw plus other fixation, nonscrew fixation. Patients with prior hallux metatarsophalangeal joint arthrodesis did not have a significantly higher nonunion rate than patients without prior first metatarsophalangeal joint arthrodesis. Patients diagnosed with radiographic nonunion were at higher risk for reoperation (P < .0001). CONCLUSION: Our cohort represents the largest single-center series of HIPJA procedures published to date. We found relatively high nonunion and reoperation rates with standard current techniques. LEVEL OF EVIDENCE: Level III, retrospective case series.

Acquired Hallux Varus Deformity Correction: Pivotless Distraction Technique.

Acquired hallux varus deformity secondary to postburn contracture is a rare condition. It causes cosmetic disfigurement, pain, and inability to wear a shoe. Soft-tissue procedures and tendon transfers have been described for correction; however, these may require multiple operations and the outcome may be poor. We report a 6-year-old neglected case of hallux varus deformity secondary to burn contracture successfully managed by contracture release with pivotless distraction technique using a biplanar distractor and skin grafting with Z-plasty in the same procedure. The deformity was corrected to a lesser extent and with good functional outcomes. The scar was excised and Z-plasty was performed. The medial joint capsule was released. We used gradual differential distraction with monitoring on sequential radiographs. Pain-free flexion of 45° and extension of 40° were achieved and the patient was able to wear shoes after 4 weeks postoperatively. Hallux varus is a multidimensional deformity. A severe and rigid deformity might not respond well to tendon transfers in a single stage. Our described technique can be used to correct rigid hallux varus deformity with preservation of joint function.

A Subungual Nevoid Melanoma of the Right Hallux from a 65-Year-Old Man: A Case Report.

Nevoid melanoma (NeM) is a rare variant of malignant melanoma characterized by slight cellular atypia, polymorphism, and incomplete maturation. It most frequently occurs on the trunk and arms but rarely on the foot. Here, we report a subungual NeM of the right hallux. A 65-year-old man presented with severe pain of 6 months' duration to his right great toe following self-treatment for an ingrown nail. He was evaluated and treated with debridement of the toenail at an urgent medical center 3 months prior. However, this had not relieved his pain. The patient also noticed discoloration of his distal great toe over the past 3 months. Removal of part of the ingrown nail revealed a pigmented mass extending distally from the matrix. Surgical excision of the mass was performed because of the concern for malignancy. The diagnosis of NeM was based on histologic analysis along with enhanced diagnostic modalities. The patient was further treated with surgical amputation of the great toe and anti-programmed cell death-1 therapy. The patient had no relapse at 1-year follow-up. Nevoid melanoma is a rare variant of malignant melanoma on the toes, which needs to be differentiated from a nevus with atypia, with a variety of modalities including cellular and molecular profiling. The optimal treatment is amputation.

The reconstruction of fingertip injury by mini hallux toenail flap pedicled with the hallux transverse artery and toe pulp vein transplantation technique based on the equivalent design theory.

INTRODUCTION: How to reconstruct the damaged fingertip is a clinical problem. Our team propose the theory of equivalent design and use the mini toenail flap pedicled with the hallux transverse artery and toe pulp vein transplantation technique to reconstruct Allen's type II fingertip injury. Thus, we perform the retrospective study to evaluate the effects of this technique on fingertip injury. MATERIALS AND METHODS: A retrospective analysis was performed on 56 patients admitted to our hospital from January 2015 to January 2020 who used equivalently designed miniature hallux toenail flaps for the plastic repair of fingertip damage. We recorded the size of the miniature hallux toenail flap, operation time, intraoperative blood loss, and complications and calculated the survival rate of the transplanted miniature hallux toenail flap. During routine follow-up after surgery, we recorded nail growth time and observed finger appearance. At the last time of follow-up, we recorded Semmes-Weinstein evaluating tactile sensation and Two-point discrimination testing (TPD). The efficacy was evaluated by Zook score evaluation. RESULTS: The size of the mini hallux toenail flap was 0.71 cm × 1.22 cm to 0.88 cm × 1.71 cm. The operation time was (3.54 ± 0.58) hours, the intraoperative blood loss was (20.66 ± 4.87) ml, and the survival rate of mini hallux toenail flaps was 100%. The postoperative follow-up time was (30.82 ± 11.21) months, and the total nail growth time was (9.68 ± 2.11) months. The average tactile sensation evaluated by the Semmes-Weinstein test was (0.32 ± 0.14) g, and the average TPD was (7.33 ± 1.02) mm. According to Zook score, the curative effect of fifty-six cases were all excellent or good with 100% excellent and good rate, and all patients had beautiful appearances and good function of damaged fingertips. CONCLUSIONS: Based on the equivalent design theory, the mini hallux toenail flap pedicled with the hallux transverse artery and toe pulp vein transplantation technique is an effective method to reconstruct Allen's type II fingertip injury with a beautiful appearance and good function. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Surgical management of osteochondral lesions of the first metatarsal head: A systematic review.

BACKGROUND: Treating osteochondral lesions of the first metatarsal head can help reducing pain and preventing end-stage arthritic cartilage degeneration and hallux rigidus. Several surgical techniques have been described, but no clear indications are reported. This systematic review aims to offer an overview of the current surgical treatments for focal osteochondral lesions of the first metatarsal head. METHODS: The selected articles were examined to extract data about population, surgical technique, and clinical outcomes. RESULTS: Eleven articles were included. Mean age at surgery was 38,2 years. Osteochondral autograft was the most used technique. After surgery, an improvement was achieved in AOFAS, VAS, and hallux dorsiflexion but not in plantarflexion. CONCLUSION: There is limited evidence and knowledge regarding the surgical management of the first metatarsal head osteochondral lesions. Various surgical techniques have been proposed, drawn from other districts. Good clinical results have been reported. Further high-level comparative studies are necessary to design an evidence-based treatment algorithm.

Functional and aesthetic recovery of the second toe defect using a wrap-around pedicled flap from the great toe.

We report the results of using a fibula-sided digital artery pedicled flap from the great toe to cover the second toe free flap donor site, which avoids delayed wound healing, and prevents pain and skin ulceration. This study included 15 patients who had second toe wrap-around free flaps to reconstruct thumb and finger defects. All 15 pedicled flaps used to cover the defect healed uneventfully. All patients were able to stand and walk and were satisfied with the postoperative aesthetic outcome at the 6-month follow-up. We conclude that this an effective procedure for preventing donor site defects after second toe wrap-around free flap transfer.Level of evidence: IV.

A Neglected Extensor Hallucis Longus Tendon Rupture Caused by Arthritic Adhesion.

Extensor hallucis longus tendon injury is relatively rare and is principally caused by a laceration when a sharp object is dropped on the instep. Primary suturing is possible if the injury is acute, but if the tear is chronic, tendon contracture causes the space between the edges of the tear to widen, disrupting the end-to-end connection. In particular, a claw toe or checkrein foot deformity may develop over time due to adhesion of the lower leg tendons near the fracture site or scar. We report on a 44-year-old man who visited our outpatient clinic complaining of pain in the right foot and a hindered ability to extend his great toe. He had enjoyed playing soccer during his schooldays; since that time, the extension of that toe had become somewhat difficult. T2-weighted sagittal magnetic resonance imaging revealed that the continuity of the extensor hallucis longus tendon had been lost at the distal phalangeal base attachment site, and that the region of the proximal tendon was retracted to level of the middle shaft of the proximal phalanx. The findings allowed us to diagnose extensor hallucis longus tendon rupture accompanying osteoarthritic changes in the joint and soft tissues. We performed surgical tenorrhaphy and adhesiolysis. This is a rare case of extensor hallucis longus tendon rupture caused by minor trauma. Arthritis that developed at a young age caused the adhesions. If patients with foot and ankle arthritis show tendon adhesion at the arthritic site, tendon rupture can develop even after minor trauma or intense stretching.

Small Joint Arthroscopy of the Foot.

Recently, there have been new advances in the arthroscopic approach to small joints of the foot. This is directly related to the improvement of surgical equipment, new techniques, and publications. These improvements led to broadening indications as well as minimizing complications. Several articles recently presented the uses of arthroscopic surgery in the small joints of the foot; however, the use is still relatively limited. Arthroscopic evaluation of the small joints of the foot includes the first metatarsophalangeal, lesser metatarsophalangeal, tarsometatarsal, talonavicular, and calcaneocuboid joints as well as the interphalangeal joint to the great toe and lesser toes.