Biomechanical effects of adding an articulating toe joint to a passive foot prosthesis for incline and decline walking.

Walking on sloped surfaces is challenging for many lower limb prosthesis users, in part due to the limited ankle range of motion provided by typical prosthetic ankle-foot devices. Adding a toe joint could potentially benefit users by providing an additional degree of flexibility to adapt to sloped surfaces, but this remains untested. The objective of this study was to characterize the effect of a prosthesis with an articulating toe joint on the preferences and gait biomechanics of individuals with unilateral below-knee limb loss walking on slopes. Nine active prosthesis users walked on an instrumented treadmill at a +5° incline and -5° decline while wearing an experimental foot prosthesis in two configurations: a Flexible toe joint and a Locked-out toe joint. Three participants preferred the Flexible toe joint over the Locked-out toe joint for incline and decline walking. Eight of nine participants went on to participate in a biomechanical data collection. The Flexible toe joint decreased prosthesis Push-off work by 2 Joules during both incline (p = 0.008; g = -0.63) and decline (p = 0.008; g = -0.65) walking. During incline walking, prosthetic limb knee flexion at toe-off was 3° greater in the Flexible configuration compared to the Locked (p = 0.008; g = 0.42). Overall, these results indicate that adding a toe joint to a passive foot prosthesis has relatively small effects on joint kinematics and kinetics during sloped walking. This study is part of a larger body of work that also assessed the impact of a prosthetic toe joint for level and uneven terrain walking and stair ascent/descent. Collectively, toe joints do not appear to substantially or consistently alter lower limb mechanics for active unilateral below-knee prosthesis users. Our findings also demonstrate that user preference for passive prosthetic technology may be both subject-specific and task-specific. Future work could investigate the inter-individual preferences and potential benefits of a prosthetic toe joint for lower-mobility individuals.

Adding a toe joint to a prosthesis: walking biomechanics, energetics, and preference of individuals with unilateral below-knee limb loss.

Toe joints play an important functional role in able-bodied walking; however, for prosthesis users, the effect of adding a toe joint to a passive prosthetic foot remains largely unknown. The current study explores the kinematics, kinetics, rate of oxygen consumption and user preference of nine individuals with below-knee limb loss. Participants walked on a passive prosthetic foot in two configurations: with a Flexible, articulating toe joint and with a Locked-out toe joint. During level treadmill gait, participants exhibited a decrease in Push-Off work when using the Flexible toe joint prosthesis versus the Locked toe joint prosthesis: 16% less from the prosthesis (p = 0.004) and 10% less at the center of mass level (p = 0.039). However, between configurations, participants exhibited little change in other gait kinematics or kinetics, and no apparent or consistent difference in the rate of oxygen consumption (p = 0.097). None of the traditional biomechanical or metabolic outcomes seemed to explain user preference. However, an unexpected and intriguing observation was that all participants who wore the prosthesis on their dominant limb preferred the Flexible toe joint, and every other participant preferred the Locked configuration. Although perhaps coincidental, such findings may suggest a potential link between user preference and limb dominance, offering an interesting avenue for future research.

Poor prognostic factors in predicting abatacept response in a phase III randomized controlled trial in psoriatic arthritis.

In ASTRAEA (NCT01860976), abatacept significantly increased American College of Rheumatology criteria 20% (ACR20) responses at Week 24 versus placebo in patients with psoriatic arthritis (PsA). This post hoc analysis explored relationships between prospectively identified baseline characteristics [poor prognostic factors (PPFs) ] and response to abatacept. Patients were randomized (1:1) to receive subcutaneous abatacept 125 mg weekly or placebo for 24 weeks; those without ≥ 20% improvement in joint counts at Week 16 switched to open-label abatacept. Potential predictors of ACR20 response were identified by treatment arm using multivariate analyses. Likelihood of ACR20 response to abatacept versus placebo was compared in univariate and multivariate analyses in subgroups stratified by the PPF, as defined by EULAR and/or GRAPPA treatment guidelines. Odds ratios (ORs) were generated using logistic regression to identify meaningful differences (OR cut-off: 1.2). 424 patients were randomized and treated (abatacept n = 213; placebo n = 211). In abatacept-treated patients, elevated C-reactive protein (CRP), high Disease Activity Score based on 28 joints (CRP), presence of dactylitis, and ≥ 3 joint erosions were identified as predictors of response (OR > 1.2). In placebo-treated patients, only dactylitis was a potential predictor of response. In the univariate analysis stratified by PPF, ACR20 response was more likely (OR > 1.2) with abatacept versus placebo in patients with baseline PPFs than in those without; multivariate analysis confirmed this finding. Response to abatacept versus placebo is more likely in patients with features indicative of high disease activity and progressive disease; these characteristics are recognized as PPFs in treatment guidelines for PsA.

Ideal implant choice for proximal interphalangeal joint arthrodesis in hammer toe/claw toe deformity correction: A systematic review.

Intramedullary devices have been developed to reduce the problems associated with Kirschner (K)-wire fixation in proximal interphalangeal joint (PIPJ) arthrodesis. The purpose of this systematic review is to compare the surgical outcomes of K-wires versus novel internal fixation devices in PIPJ arthrodesis in claw/hammer toe surgery. The databases searched were PubMed, Scopus, Cochrane, and Embase with keywords "claw toe OR hammer toe" AND "proximal interphalangeal OR PIP" AND "fusion OR arthrodesis." Clinical trials published in English with evidence levels I, II, and III were included. Five studies, including one randomized controlled trial and four case-controlled studies, were identified to meet the inclusion criteria. Overall, the studies showed promising results in union rates using the novel internal devices compared to K-wires. However, the novel internal devices seem not to present advantages in clinical parameters such as pain levels, patient satisfaction, foot-related function, or surgical complication rates.

Palmar/plantar approach for radiographic-guided injection of the equine distal interphalangeal joint collateral ligament insertion.

There are limited radiographic-guided injection techniques of the insertion of the distal interphalangeal joint (DIPJ) collateral ligaments. The objective of this study was to develop and evaluate a palmar/plantar radiographic-guided injection of the collateral ligament insertion in cadavers. Fifty limbs were used to develop the technique and 24 additional limbs were used to evaluate accuracy. An 18 G, 9 cm spinal needle was placed in the depression between the palmar digital neurovascular bundle and arch of the ungular cartilage with dorsodistal advancement towards the distal phalanx collateral fossa. Radiographs verified ideal needle location on the proximal border of the distal phalanx at the collateral fossa. Dye was injected. Hoof walls were partially removed and collateral ligaments were dissected with needles in place to determine needle and dye location. Accuracy of needle placement into the insertion of the DIPJ collateral ligament was 41/48 (85 per cent), with lower accuracy of dye within the ligament (34/48; 71 per cent). Dye entered the DIPJ in 2/48 injections, but dye entered periligamentous structures in 22/48 (46 per cent) injections. A palmar/plantar radiographic-guided injection of the insertion of the DIPJ collateral ligament had high accuracy rate with low injection rate of the DIPJ in cadavers.

Proximal Interphalangeal Arthrodesis of Lesser Toes Utilizing K-Wires Versus Expanding Implants: Comparative Biomechanical Cadaveric Study.

BACKGROUND:: Lesser toe proximal interphalangeal (PIP) joint arthrodesis is one of the most common foot and ankle elective procedures often using K-wires for fixation. K-wire associated complications led to development of intramedullary fixation devices. We hypothesized that X Fuse (Stryker) and Smart Toe (Stryker) would provide stronger and stiffer fixation than K-wire fixation. METHODS:: 12 cadaveric second toe pairs were used. In one group, K-wires stabilized 6 PIP joints, and 6 contralateral PIP joints were fixed with X Fuse. A second group used K-wires to stabilize 6 PIP joints, and 6 contralateral PIP joints were fixed with Smart Toe. Specimens were loaded cyclically with extension bending using 2-N step increases (10 cycles per step). Load to failure and initial stiffness were assessed. Statistical analysis used paired t tests. RESULTS:: K-wire average failure force, 91.0 N (SD 28.3), was significantly greater than X Fuse, 63.3 N (SD 12.9) ( P < .01). K-wire average failure force, 102.3 N (SD 17.7), was also significantly greater than Smart Toe, 53.3 N (SD 18.7) ( P < .01). K-wire initial stiffness 21.3 N/mm (SD 5.7) was greater than Smart Toe 14.4 N/mm (SD 9.3) ( P = .02). K-wire failure resulted from bending of K-wire or breaching cortical bone. X Fuse typically failed by implant pullout. Smart Toe failure resulted from breaching cortical bone. CONCLUSION:: K-wires may provide stiffer and stronger constructs in extension bending than the X Fuse or Smart Toe system. This cadaver study assessed stability of the fusion site at time zero after surgery. CLINICAL RELEVANCE:: Our findings provide new data supporting biomechanical stability of K-wires for lesser toe PIP arthrodesis, at least in this clinically relevant mode of cyclic loading.

Methotrexate achieves major cDAPSA response, and improvement in dactylitis and functional status in psoriatic arthritis.

OBJECTIVE: Despite the widespread clinical use of MTX in PsA, data from published randomized controlled studies suggest limited efficacy. The objective of the present study was to document the efficacy of MTX. METHODS: This was an open-label, prospective study of patients satisfying the ClASsification criteria for Psoriatic ARthritis study (CASPAR) criteria for PsA who received MTX in doses of ⩾15 mg/week throughout the follow-up period of 9 months. Disease activity was assessed across various domains by tender and swollen joint count, physician and patient global assessment, DAS-28 ESR, Clinical Disease Activity Index for PsA (cDAPSA), Leeds Dactylitis Instrument basic, Leeds Enthesitis Index (LEI), Psoriasis Area and Severity Index (PASI), Minimal Disease Activity and HAQ (CRD Pune version) at baseline and at 3, 6 and 9 months of follow-up. Response to therapy was assessed by EULAR DAS28 ESR, Disease Activity Index for PsA (cDAPSA) response, HAQ response and PASI75. MTX dose escalation and the use of combination DMARDS were dictated by disease activity. RESULTS: A total of 73 patients were included, with mean (s.d.) age 44 (9.7) years. The mean (s.d.) dose of MTX used was 17.5 (3.8) mg/week. Seven patients received additional DMARDS (LEF/SSZ). At the end of 9 months, significant improvement (P < 0.05) was noted in the tender joint count, swollen joint count, global activity, DAS-28ESR, cDAPSA, Leeds Dactylitis Index basic, LEI, PASI and HAQ. Major cDAPSA response was achieved in 58.9% of patients. EULAR DAS28 moderate and good response was achieved in 74% and 6.8% of patients, respectively. Minimal Disease Activity was achieved in 63% of patients. A PASI75 response and HAQ response was achieved in 67.9% and 65.8% of patients, respectively. CONCLUSION: MTX initiated at ⩾15 mg/week with targeted escalation resulted in significant improvement in the skin, joint, dactylitis, enthesitis and functional domains of PsA.

Rápida resolución de la dactilitis en un paciente con artritis psoriásica tras tratamiento con ustekinumab / Rapid dactylitis resolution in a patient with psoriatic arthritis after treatment with ustekinumab

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Poor toe flexor strength, but not handgrip strength, is associated with the prevalence of diabetes mellitus in middle-aged males.

Previous studies suggested that reduced muscular strength was one of the potential predictor of prevalence of diabetes mellitus. The purpose of this study was to investigate the association between toe flexor strength (TFS) and handgrip strength (HGS) and the prevalence of diabetes mellitus. Cross-sectional analysis was conducted using data from 1,390 Japanese males (35-59 years). TFS and HGS were measured and medical examinations undertaken. The prevalence of diabetes mellitus was defined as fasting blood glucose ≥126 mg/dL, glycated hemoglobin ≥6.5% (48 mmol/mol), and/or current use of anti-diabetes mellitus drugs. A total of 114 participants had diabetes mellitus. TFS in participants with diabetes mellitus was significantly lower than that in persons not suffering from diabetes mellitus but HGS was not. Odds ratio (OR) and 95% confidence interval (CI) per 1-standard deviation-increase in muscular strength measurements for the prevalence of diabetes mellitus were obtained using a multiple logistic regression model. Prevalence of diabetes mellitus was inversely related to TFS (OR 0.769, 95% CI 0.614-0.963), TFS/body mass (BM) (0.696, 0.545-0.889) and TFS/body mass index (BMI) (0.690, 0.539-0.882) after adjustment of covariates. Such associations were not observed in HGS (OR 0.976, 95% CI 0.773-1.232), HGS/BM (0.868, 0.666-1.133) or HGS/BMI (0.826, 0.642-1.062). These results suggested that poor TFS was associated with an increased prevalence of diabetes mellitus independent of visceral fat accumulation, but HGS was not, in middle-aged males. TFS may be a better marker for the prevalence of diabetes mellitus than HGS.

Comparative Study of Intramedullary Hammertoe Fixation.

BACKGROUND: Temporary Kirschner wire fixation (K-wire) is a widely used, low-cost fixation method for the correction of hammertoe deformity. Reported complications associated with K-wires prompted the development of new implants over the past decade. However, there is a lack of literature on comparative studies analyzing functional outcomes using validated questionnaires. The purpose of this study was to analyze functional outcomes in patients who had undergone proximal interphalangeal joint fusion using 2 types of intramedullary implant, the Smart Toe and the TenFuse, and to compare them with the outcomes in patients treated with standard K-wire fixation. METHODS: A retrospective review of operative hammertoe correction by a single surgeon was performed in 96 patients followed for more than 12 months. Functional outcome was assessed using the Foot Function Index (FFI), the Short Form 36 (SF-36), and the 10-point visual analog scale (VAS) validated questionnaires. Complications and fusion rates were also evaluated. Several patients in the study underwent corrections in different toes; thus, a total of 186 toes were included in the study. From these, 65 toes (34.9%) were treated with K-wire fixation, 94 (50.5%) with Smart Toe titanium implant, and 27 (14.5%) with TenFuse allograft implant. RESULTS: No statistically significant differences in functional outcome and incidence of complications were observed among the 3 fixation groups, although the 2 intramedullary implants were associated with greater fusion rates and patient satisfaction. Breakage of the Smart Toe implant was significantly higher than that of the other fixations, with 10.6% of implants breaking within the first year postoperatively. SF-36 and VAS scores decreased 12 months after surgery for the 3 types of fixation, with no statistically significant differences observed. CONCLUSION: The use of Smart Toe and TenFuse implants provided operative outcomes comparable to those obtained using a K-wire fixation and slightly better patient satisfaction. Our results suggest that utilization of these implants for hammertoe correction was a reasonable choice that provided good alignment, pain reduction, and improved function at final follow-up. However, they are more expensive than K-wires. For this reason, in-depth cost-benefit studies would be required to justify their use as a standard treatment. LEVEL OF EVIDENCE: Level III, comparative series.

The impact of transferred vascularized toe joint length on motion arc of reconstructed finger proximal interphalangeal joints: a cadaveric study.

Vascularized toe joint transfer for finger proximal interphalangeal joint reconstruction can result in sub-optimal arc of motion and extension lag due to inappropriate intercalated bony segment length. We investigated the impact of intercalated segment length on passive arc of motion and extension lag of the reconstructed proximal interphalangeal joint. Cadaveric intercalated joint grafts were harvested from lesser toes and transferred to cadaveric fingers. The pre-determined finger proximal interphalangeal joint defect size was 2 cm. Three different intercalated segment lengths were inserted and resulting proximal interphalangeal joint arc of motion and extension lag were measured. The average arc of motion of finger proximal interphalangeal joints was 81° and 54° for toe proximal interphalangeal joints. Long intercalated segments had an average arc of motion of 30° with 32° extension lag. Equal-length intercalated segments had an average 49° arc of motion with 15° extension lag. Short intercalated segments had an average arc of motion of 71° with 8° extension lag. Shorter intercalated segments provide the greatest reduction in extension lag.

A Midterm Review of Lesser Toe Arthrodesis With an Intramedullary Implant.

Lesser toe deformities are one of the most common conditions encountered by podiatric surgeons. When conservative treatments fail surgical correction is indicated. Many surgical options have been described to address the complex nature of these deformities but no perfect solution has been reported to date. However, with the continued advancement of internal fixation technology, interphalangeal joint (IPJ) arthrodesis with an intramedullary implant may be a good option. This retrospective study presents patient reported outcomes and complications at 6 months and 3 years following lesser toe proximal interphalangeal joint (PIPJ) arthrodesis with a polyketone intrameduallary implant (Toe Grip, Orthosolutions, UK). Between September 2011 and November 2012, a total of 38 patients attended for second toe PIPJ arthrodesis by means of the Toe Grip device. At 6 months postoperation, 94.7% of patients and at 3 years postoperation, 92.8% of patients felt that their original complaint was better or much better. Health-related quality of life scores continued to improve overtime as measured by the Manchester Oxford Foot Questionnaire. Complications were generally observational and asymptomatic. The most common complications were floating toes (17.8%), mallet deformities (14.2%), metatarsalgia (17.8%), and transverse plane deformity of the toe (10.7%). This study demonstrates excellent patient-eported outcomes with minimal symptomatic complications making the "Toe Grip" implant a safe and effective alternative fixation device for IPJ arthrodesis when dealing with painful digital deformities. LEVELS OF EVIDENCE: Therapeutic, Level IV: Case series.

Association between preoperative pain intensity of MTP joint callosities of the lesser toes and fore-mid-hindfoot deformities in rheumatoid arthritis cases.

OBJECTIVES: To determine whether preoperative pain intensity in callosities of the lesser toe metatarsopharangeal (MTP) joint was associated with the grade of fore-mid-hindfoot deformities, because rheumatoid arthritis (RA) foot deformity includes the whole part of foot, and curiously differences between cases in the pain intensity of MTP joint callosities are often observed. METHODS: We evaluated 24 feet that had undergone forefoot surgery [August, 2014 - December, 2015] for painful lesser toe MTP joint deformity (callosities) in RA cases. A preoperative self-administered foot evaluation questionnaire (SAFE-Q) and pressure distribution information for foot function were also investigated. X-rays of the whole lower extremities and foot at weight-bearing were used to check fore-mid-hindfoot deformities. RESULTS: Group M (mild) [n = 9] included patients with the pain visual analog scale (VAS) less than 40 mm, while group S (severe) [n = 15] included patients whose VAS was over 40 mm. Group M showed stronger hindfoot valgus and pronated (abducted) deformity, and group M showed higher pressure on the first MTP joint compared with group S. CONCLUSIONS: These observations reconfirm that hindfoot valgus deformity and/or pronated (abducted) foot deformity affects the forefoot loading distribution, subsequently the pain of callosities in lesser toe MTP joints could be decreased.

Enthesitis as a component of dactylitis in psoriatic juvenile idiopathic arthritis: histology of an established clinical entity.

CONTEXT: Imaging of dactylitis in adult psoriatic arthritis suggests a pathophysiological role for enthesitis. However, histological definition of the dactylitic digit is unavailable. OBJECTIVE: We evaluated the role of enthesitis in dactylitis associated with psoriatic juvenile idiopathic arthritis (psJIA) in a child who underwent detailed imaging and histologic evaluation. DESIGN: Radiographs, ultrasound and high-resolution magnetic resonance imaging were employed to define the locus of disease in two dactylitic digits from a 14-year-old girl with psJIA. Biopsies were stained with hematoxylin and eosin, CD3, CD20, CD4, CD8 and CD117 and examined via light microscopy. RESULTS: Radiologic features of dactylitis included enhanced signal at digital entheses without accompanying synovitis or tenosynovitis. Histologically, finger and toe tissue exhibited hypervascular tenosynovium with a fibromyxoid expansion of fibrous tissue. This was accompanied by sparse to moderate perivascular lymphocytic inflammation consisting predominantly of T cells, with occasional admixed B cells and mast cells. Neutrophils and plasma cells were absent. Fibrocartilage exhibited reactive features including increased extracellular myxoid matrix, binucleation, and focal necrosis, without cellular inflammation. Fibrinous synovitis and mild reactive synoviocyte hyperplasia were seen. CONCLUSIONS: Dactylitis in psJIA bears a radiographic resemblance to the condition in adult psoriatic arthritis. Histologic hallmarks include an expanded mast cell-populated extracellular myxoid matrix, cartilage degeneration, and a T cell-rich perivascular inflammatory infiltrate. These findings help to define enthesitis as a clinicopathologic entity.

The association between hallux valgus and proximal joint alignment in young female dancers.

Very little is known about the relationship between proximal joint alignment and hallux valgus among young dancers. This study sought to determine the extent to which spinal and lower extremity alignments are involved in hallux valgus, and to identify predicting variables for its development in young dancers. A group of 1336 young female dancers aged 8-16 years, and 226 control participants of the same age cohort were screened for the presence of hallux valgus, body physique characteristics, joint range of motion, and anatomical anomalies. Hallux valgus was common in the 2 young female populations studied. Among the dancers, 40.0% had bilateral hallux valgus and 7.3% unilateral. Among the controls, 32.3% had bilateral and 1.8% unilateral hallux valgus (χ2=8.27, df=1, p=0.004). Following logistic regression analysis, age (OR=1.028, 95% CI=0.968-1.091), genu varum (OR=1.514; CI=1.139-2.013) and scoliosis (OR=2.089; CI=1.113-3.921) were found to be significant predicting factors for hallux valgus in the dancer group, whereas in the control group, the predicting factors were age (OR=0.911, 95% CI=0.801-1.036) and ankle plantar flexion range of motion (OR=0.972; CI=0.951-0.992). In conclusion, it was found that spinal deformity, lower extremity alignment, and joint range of motion are strongly related to hallux valgus.

Minimally invasive proximal interphalangeal joint arthrodesis using a locking compression plate and tissue engineering in horses: a pilot study.

This pilot study assessed the efficacy of 2 minimally invasive techniques for proximal interphalangeal (PIP) joint arthrodesis in horses. The PIP joints of both forelimbs (n = 6) were stabilized with locking compression plates (LCP) using a minimally invasive technique (LCP technique). Subsequently, for 1 randomly selected PIP joint of each horse, surgical drilling (SurD) was performed and tissue engineering (TE) was applied (LCP/SurD/TE technique). Minimally invasive PIP joint arthrodesis with LCP demonstrated low postoperative infection rates. Gross and histological evaluations revealed considerable destruction of the articular cartilage in the LCP/SurD/TE-treated joints. In contrast, almost no destruction of the cartilage was observed in the LCP-treated joints. Our results suggest that the LCP technique alone is not sufficient for PIP joint arthrodesis and that the LCP/SurD/TE technique may be useful for PIP joint arthrodesis in horses.

Arthrodèse de l'articulation interphalangienne proximale à effraction minimale à l'aide d'une plaque de fixation à compression et de l'ingénierie tissulaire chez les chevaux : une étude pilote. Cette étude pilote a évalué l'efficacité de 2 techniques à effraction minimale pour l'arthrodèse de l'articulation interphalangienne proximale (AIP) chez les chevaux. Les articulations AIP des deux membres antérieurs (n = 6) ont été stabilisées avec des plaques de fixation à compression (PFC) à l'aide d'une technique à effraction minimale (technique PFC). Subséquemment, pour une articulation AIP choisie au hasard pour chaque cheval, un fraisage chirurgical (FC) a été réalisé et une ingénierie tissulaire (IT) a été appliquée (technique PFC/FC/IT). Une arthrodèse de l'articulation AIP à effraction minimale avec PFC a démontré de faibles taux d'infection postopératoire. Des évaluations brutes et histologiques ont révélé une destruction considérable du cartilage articulaire dans les articulations traitées à l'aide de la technique PFC/FC/IT. Par contraste, pratiquement aucune destruction du cartilage n'a été observée dans les articulations traitées par PCF. Nos résultats suggèrent que la technique PFC seule n'est pas suffisante pour l'arthrodèse des articulations AIP et que la technique PFC/FC/IT peut être utile pour l'arthrodèse de l'articulation AIP chez les chevaux.(Traduit par Isabelle Vallières).

Hallux valgus in dancers: a closer look at dance technique and its impact on dancers' feet.

Hallux valgus is a common deformity of the forefoot. There is no doubt that some dancers develop hallux valgus, but the question remains as to whether dancers are at greater risk than the general population for developing this deformity. Review of the literature reveals on-going debate regarding risk factors for hallux valgus, which may include increasing age, female gender, genetic predisposition, constrictive shoe wear, first ray hypermobility, foot architecture, tight Achilles tendon, and first metatarsal length. There is insufficient evidence to demonstrate conclusively that dancing, specifically pointe work, increases the prevalence or severity of hallux valgus; more research is needed. Treatment of hallux valgus in dancers should be conservative, with delay of surgical correction until retirement if possible.

The effect of flexor hallucis longus harvest on hallux function: a retrospective cross-sectional cohort study.

BACKGROUND AND AIM: Our aim was to evaluate the long-term morbidity of the hallux function after harvesting a free fibula flap. Special attention was given to the differences between patients who underwent the dissection of an osteo-cutaneous flap (without inclusion of the flexor hallucis longus (FHL) muscle) and patients who were treated with an osteo-myo-cutaneous (with inclusion of the FHL muscle). METHODS: During the period 1995-2009, 167 patients underwent an autologous mandible reconstruction using a free fibula flap. By the time of our investigation, 64 patients were deceased, 29 patients were lost to follow-up, 14 patients did not meet the inclusion criteria and 28 patients were unable or unwilling to come to the hospital. Thus, 32 patients were examined in this study. Combined flexion strength of the hallux flexors and range of motion (ROM) of the metatarsophalangeal (MTP) and interphalangeal (IP) joints were measured. RESULTS: Hallux flexion strength tests showed a significant decrease in strength in the operated leg versus control, 28±16.6 versus 37±19.2 N/s (p=0.003). The ROM for the MTP was significantly lower for the donor leg than for the control leg: 26±12° versus 30±10° (p=0.024) for plantar flexion and 30±13° versus 37±11° (p<0.001) for dorsal flexion. In addition, the ROM for plantar flexion in the IP joint was significantly lower in the donor group. No significant differences were found when comparing reduction of flexion strength or reduction of ROM in the osteo-cutaneous versus osteo-myo-cutaneous harvest. CONCLUSIONS: The main conclusion to be drawn from our results is that free fibula flap donor site morbidity in terms of hallux function is independent of the inclusion or exclusion of the FHL muscle in the flap. LEVEL OF EVIDENCE III: Retrospective cohort or comparative study; case-control study; or systematic review of these studies.