Review of Drop Hallux: Assessment and Surgical Repair.

Peroneal nerve palsy is common. The hallmark clinical manifestation of peroneal nerve palsy is drop foot. In the drop foot condition, the ankle cannot flex, and the foot does not clear the ground during the swing phase of gait. Spontaneous nerve repair can yield complete or incomplete resolution of drop foot. Some patients with incomplete resolution are left with a drop hallux condition, in which the ankle can dorsiflex, but the hallux remains unable to dorsiflex. This has not been thoroughly discussed in the past, regarding surgical repair. In the present report, we have reviewed the drop hallux condition and an effective surgical repair option (extensor hallucis longus to tibialis anterior tendon anastomosis). Our case report presents a healthy 27-year-old male who had persistent drop hallux after drop foot resolution, 3 years after external fixation of a closed, proximal tibia-fibula fracture.

Immediate Weightbearing of First Metatarsophalangeal Joint Fusion Comparing Buried Crossed Kirschner Wires Versus Crossing Screws: Does Incorporating the Sesamoids Into the Fusion Contribute to Higher Incidence of Bony Union?

First metatarsophalangeal joint (MTPJ) arthrodesis remains a commonly used and reliable procedure for a variety of pathologies of the first MTPJ. Many costly fixation constructions have been described to achieve union with first MTPJ arthrodesis. We hypothesized that the incidence of union would be the same for both buried Kirchner (K)-wire and solid crossed screw fixation with immediate weightbearing. To test this hypothesis, we retrospectively reviewed first MTPJ fusions performed by the senior author (C.A.C.) during a 6-year period and compared the incidence of union. Only patients who were immediately weightbearing in a surgical shoe and had undergone first MTPJ arthrodesis using K-wires or crossed screws were included. All patients had undergone incorporation of their sesamoids into the fusion. A total of 97 feet in 89 patients met the inclusion criteria. Of the 97 first MTPJ fusions, 48 (49.5%) had buried K-wire fixation and 49 (50.5%) crossed screw fixation. The mean age was 62 (range 41 to 75) years in the K-wire group and 60 (range 22 to 73) years in the crossed screw group. The mean follow-up period was 12.4 months in the K-wire group and 12.9 months in the crossed screw group. The rate of union in the K-wire group was 98% (1 nonunion) and the rate of union in the crossed screw group was 96% (2 nonunions). The 2 groups demonstrated similar high rates of fusion with immediate weightbearing, suggesting that less costly fixation is acceptable and effective for uncomplicated first MTPJ fusion.

Subtalar Joint Distraction Arthrodesis to Correct Calcaneal Valgus in Pediatric Patients with Tarsal Coalition: A Case Series.

Subtalar joint middle facet coalitions commonly present in children who have a painful, rigid, pes planovalgus foot type. The middle facet coalition allows rearfoot forces to be distributed medially through the coalition, and this can result in arthritis or lateral tarsal wedging. The senior author has used a wedged bone graft distraction subtalar joint arthrodesis to correct calcaneal valgus and restore the talar height in these patients. The tight, press-fit nature of the tricortical iliac crest allograft provides stability and can negate the need for internal fixation. We retrospectively reviewed 9 pediatric subtalar joint distraction arthrodesis procedures performed on 8 patients during a 6-year period. All patients began weightbearing at 6 weeks after surgery. All patients had osseous union, and no complications developed that required a second surgery. The clinical outcomes, assessed at a mean of 25.5 (range, 6.3 to 75.8) months postoperatively, were satisfactory. The mean American Orthopaedic Foot and Ankle Society score was 90.1 (range, 79 to 94), on a 94-point scale. The wedged distraction arthrodesis technique has not been previously described for correction of pediatric patients with lateral tarsal wedging, but it is an effective option and yields successful outcomes.

Lapidus arthrodesis with a single lag screw and a locking H-plate.

The aim of this pilot study was to assess if using an interfragmental lag screw and a Darco(®) locking H-plate for the modified Lapidus arthrodesis in the treatment of hallux abducto valgus deformity (1) would allow for earlier weight bearing than previously described and (2) would indicate whether any changes would occur radiographically with the earlier weight bearing. Twenty-one metatarsocuneiform arthrodeses, in 18 patients, were retrospectively evaluated through chart review and postoperative radiographs. Original diagnoses included painful hallux abducto valgus and osteoarthritis of the first metatarsocuneiform joint. The mean age of the patients was 48 (range, 16 to 70) years. The mean follow-up duration was 38.5 (range, 29 to 60) months. The overall radiographic osseous union rate was 90.5% (19/21 feet), although there were 2 asymptomatic nonunions. There were no cases of fixation failure, and the surgical correction was preserved on follow-up radiographs. Overall, the mean time to full weight bearing was 4.7 (range, 3 to 7.5) weeks, and it was a mean of 8 (range, 7 to 10) weeks before the patient was back to wearing comfortable shoes. The authors concluded that metatarsocuneiform arthrodesis fixated with 1 interfragmentary lag screw and a Darco(®) locking H-plate provides sufficient stability to allow earlier weight bearing than has been previously described with other internal fixation constructs.

The unreliability of the intermetatarsal angle in choosing a hallux abducto valgus surgical procedure.

Conventional thinking holds that high intermetatarsal and hallux abductus angles (>15° and >25°, respectively) are associated with a hypermobile first ray and require a Lapidus procedure to achieve satisfactory correction for the treatment of hallux valgus. However, normal first ray motion may be misinterpreted as hypermobility, and it is possible to take advantage of this motion to correct some portion of a large hallux abductovalgus deformity with distal procedures, such as the Austin or first metatarsophalangeal joint fusion. We retrospectively examined radiographs of 61 patients with first intermetatarsal and hallux abductus angles greater than 15° and greater than 25°, respectively, who had undergone hallux abductovalgus correction via Lapidus, Austin, or first metatarsophalangeal joint fusion. Preoperative and postoperative radiographic measurements of the intermetatarsal and hallux abductus angles were made. The results revealed no statistically significant differences in the amount of correction achieved by any of the 3 procedures in comparison with the others. We concluded that, given appropriate patient selection, an Austin or first MTPJ fusion could reliably correct large intermetatarsal and hallux abductus angles that, in the hands of many surgeons, are often treated by means of Lapidus arthrodesis.

A review of tarsal coalition and pes planovalgus: clinical examination, diagnostic imaging, and surgical planning.

Pediatric pes planovalgus deformity may be classified as flexible or rigid. The rigid pes planovalgus is often a result of a tarsal coalition, which is typically characterized as a painful unilateral or bilateral deformity, frequently associated with peroneal spasm. However, many tarsal coalitions are asymptomatic and demonstrate no peroneal spasm or pes planovalgus deformity. Likewise, the severe pes planovalgus foot type can demonstrate some of the same clinical and radiographic features of a tarsal coalition, especially in the obese adolescent patient. Also, peroneal spasm may occur in the noncoalesced foot, making diagnosis and etiology more difficult to elucidate. The authors believe that many patients with a pes planovalgus deformity lie in this "gray zone": somewhere between the frank osseous coalition and the flexible pes planovalgus. The "step-forward Hubscher maneuver" is introduced as an effective means of evaluating the flexibility of a pes planovalgus foot by negating the effects of a gastrocnemius or gastrocnemius-soleus equinus. This article focuses on the clinical examination and findings of specific imaging studies to assist in an accurate diagnosis of these complicated patients. This will also help to reveal the various surgical options that are appropriate for the individual patient. Emphasis is placed on computerized tomography (CT) imaging and offers enhanced methods for ordering this test to specifically evaluate middle facet coalitions of the subtalar joint. The authors also introduce "lateral tarsal wedging," an image finding associated with severe deformities, the implications of this finding, as well as its impact on surgical planning.

A review of 51 talonavicular joint arthrodeses for flexible pes valgus deformity.

The purpose of this study was to evaluate the radiographic and clinical outcomes of isolated talonavicular arthrodesis in the treatment of the flexible pes valgus foot type. Retrospectively, 51 consecutive isolated talonavicular arthrodeses in 41 patients were evaluated. The mean patient age was 47 (range 9 to 72) years, and the mean follow-up duration was 43.3 (range 11 to 113) months. The mean 10-cm categorical pain score before the surgery was 7.60 +/- 2.37, and this improved to 1.90 +/- 2.38 postoperatively, and this difference was statistically significant (P < .001). We also measured the preoperative and postoperative percent of talar uncovering, calcaneocuboid angle, Kite's angle, talar dome height, calcaneal inclination angle, and Meary's angle, and observed statistically significant (P < .001) improvements in all of these. Fifty-one (100%) of the cases progressed to radiographic osseous union, although 2 (3.92%) of the cases were considered delayed unions. Moreover, 4 (7.84%) of the cases displayed juxta-articular arthrosis postoperatively, and 2 (3.9%) cases developed transfer pain to the lateral column. The authors concluded that isolated talonavicular arthrodesis is a safe and effective procedure for the treatment of painful pes valgus deformity.

A technique for isolated arthrodesis of the second metatarsocuneiform joint.

Arthrodesis for primary osteoarthrosis of the second metatarsocuneiform joint has received little attention in the literature when compared to salvage of posttraumatic osteoarthrosis after Lisfranc fracture dislocation. The use of screw or plate fixation is commonly advocated for such in situ arthrodesis, and the use of trephine/dowel plugs has also been described. The authors present an alternate approach for addressing primary osteoarthrosis of the second metatarsocuneiform joint with the use of Kirschner wires fashioned into staples with cancellous bone graft interposition.

A simplified technique for repair of recurrent peroneal tendon subluxation.

Peroneal tendon subluxation or dislocation denotes intermittent or chronic anterior displacement of the peroneus longus and brevis tendons out of their fibro-osseous tunnel at the distal and posterior aspect of the fibula. Numerous surgical techniques have been described to address peroneal tendon subluxation, including isolated or combined soft tissue and osseous reconstructive procedures. The authors present an efficient and simplified approach for addressing this pathology using multiple, nonabsorbable retention sutures without the need for extensive dissection or osteotomy.