Modified Valenti Arthroplasty in Running and Jumping Athletes With Hallux Limitus/Rigidus: Analysis of One Hundred Procedures.

Despite hallux limitus/rigidus being a common condition, results of surgical procedures specifically pertaining to athletes are scarce. The results of 100 modified Valenti procedures, prospectively studied from January 2000 to June 2016 with an average 49.17 months of follow-up, are presented evaluating demographics, sport, time and ability to return to activity (RTA), decreased desired activity level, and need for additional surgery. Inclusion criteria included athletes who have exhausted conservative care without relief of daily pain, dorsiflexion <20°, and grade ≥2. Seventeen had grade 2, 79 had grade 3, and 4 had grade 4 disease. RTA for the 89 procedures where exact time could be determined was 9.25 weeks; however, 100% were confirmed to RTA to some degree. The RTA of dancers and runners (the largest portion of the cohort at 76) was around 8 weeks, whereas soccer players were the slowest at >16 weeks, which was significant. There was no other significant difference in RTA between sport, sex, or grade of hallux limitus/rigidus except for between runners and soccer players. Six patients (6%) stated a decreased desire to activity, although this was not a significant finding. The modified Valenti procedure is a safe and highly effective treatment for running and jumping athletes limited by hallux limitus/rigidus because 94% of patients were able to return to their desired level of activity.

Metatarsus Primus Elevatus Resolution After First Metatarsophalangeal Joint Arthroplasty.

BACKGROUND: Hallux limitus (HL) is the second-most common pathology associated with the first metatarsophalangeal joint. A common etiology believed to be associated with HL is metatarsus primus elevatus (MPE), although causation has been unsubstantiated by evidence. Historically, correction of MPE is surgically addressed with an osteotomy. However, some believe MPE is a secondary manifestation of HL due to retrograde pressure and lack of dorsiflexion at the first metatarsophalangeal joint. This study sought to determine whether MPE resolves spontaneously after first metatarsophalangeal joint arthroplasty and reinstitution of normal joint dorsiflexion. METHODS: Twenty-seven weightbearing lateral radiographs from patients with HL were reviewed before and after nonimplant first metatarsophalangeal joint arthroplasty. Radiographs were taken preoperatively and at postoperative visits 1 (mean, 2 weeks) and 2 (mean, 10 weeks). Measurements included first to second metatarsal elevation, Seiberg Index, first to fifth metatarsal distance, sagittal plane first to second metatarsal angle, Meary's angle, metatarsal declination angle, and hallux equinus angle. RESULTS: Statistically significant improvement was seen at both postoperative visits in all of the previously mentioned measurements except first to fifth metatarsal distance, which was reduced but was not statistically significant. CONCLUSIONS: Metatarsus primus elevatus was reduced significantly after first metatarsophalangeal joint arthroplasty. Resolution occurred rapidly and was maintained at the final postoperative visit. This could be due to MPE being a manifestation of HL and not a cause. Based on the results of this study, osteotomies may be unnecessary to surgically address MPE because it can spontaneously correct after reinstitution of first metatarsophalangeal joint motion.

Complications Following Allograft and Xenograft Resurfacing of the First Metatarsal Head: A Case Series.

Ten cases using decellularized allografts and xenografts for the purpose of resurfacing the first metatarsal head are reviewed in this article. Although most of the cases were performed without any postoperative complications, the focus of this series is on 2 of the 3 cases in which destruction of the first metatarsal head was observed postoperatively due to a foreign body reaction and severe degeneration within the metatarsal head. A salvage procedure using a silicone total joint to replace the damaged surface is shown. The role of cystic changes present preoperatively, and its role in subsequent failure is examined.

A new surgical procedure for hallux limitus treatment: Double-V osteotomy on the base of the proximal phalanx of the hallux.

The purpose of this study was to evaluate the effectiveness of the new Double-V osteotomy of the first metatarsophalangeal joint (1MPJ) in patients with hallux limitus (HL).A study of 66 patients was performed, 33 patients were treated Cheilectomy and 33 were treated Double-V. All patients underwent an assessment of the passive mobility of the 1MPJ before the procedure, reevaluated 12 months later evaluating dorsiflexion, plantarflexion, and patients status using both the American Orthopaedic Foot and Ankle Society (AOFAS) for Hallux Metatarsophalangeal-Interphalangeal Scale.In comparing the improvement achieved regarding the increase of mobility obtained with surgical treatment, the feet operated with procedure Double-V gained significant degrees of movement increased in all analyzed parameters (P < .05). We achieved 13.33° more than average in dorsiflexion motion and 2.12° more than average in plantarflexion with regard to the feet that were operated with Cheilectomy procedure. Double-V scores on the AOFAS scale improved significantly (P = .000) 91.48 points postoperative, while with the following Cheilectomy only 79.30 points.This new surgical technique, easy to perform and with low complexity in surgical execution and a minimum of complications, produces better clinical and functional results that Cheilectomy alone.

Black bone disease of the foot: a case study and review of literature demonstrating a correlation of long-term minocycline therapy and bone hyperpigmentation.

The chronic use of minocycline and tetracycline has been widely reported in published studies to cause discoloration of skin and teeth. There are very few case reports with regard to discoloration of bone. Those cases reported have been termed black bone disease or blue bone disease because the resulting change to the bone is a blue, green, or brown discoloration that resembles necrotic bone. Documentation of the occurrence in bone, however, is rare, with very few studies noted and only 1 other case that reported changes to the bones of the foot. The mechanism responsible for bone discoloration is not clearly understood. We present a case of this condition encountered during cheilectomy of the first metatarsophalangeal joint in a patient who had required long-term usage of minocycline for adult acne.

First metatarsophalangeal joint arthrodesis.

Arthrodesis of the first metatarsophalangeal joint (MTPJ) is used primarily for end-stage hallux rigidus whereby pain, crepitus, and limitation of motion is noted at the joint. Arthrodesis at the first MTPJ also has it uses as a primary procedure for rheumatoid arthritis when severe deformity is present, as well as for salvage procedures for failed joint arthroplasties with or without implant, fractures with intra-articular extension, avascular necrosis, and infection management. A first MTPJ arthrodesis should provide stable fixation, attain suitable positioning for a reasonable gait, maintain adequate length, and create a stable platform for a plantigrade foot type.

Dynamic splinting for postoperative hallux limitus: a randomized, controlled trial.

BACKGROUND: Hallux limitus (HL) is a pathology of degenerative arthritis in the first metatarsophalangeal joint (MTJ) of the great toe. Chief complaints of HL include inflammation, edema, pain, and reduced flexibility. The onset of HL commonly occurs after one of the two most common surgical procedures for foot pathologies, a bunionectomy or a cheilectomy. The purpose of this study is to determine the efficacy of dynamic splinting in treating patients with postoperative hallux limitus, in a randomized, controlled trial. METHODS: Fifty patients (ages 29 to 69) were enrolled after diagnosis of HL following surgery. The duration of this study was eight weeks, and all patients received nonsteroidal anti-inflammatory drugs, orthotics, and instructions for a home exercise program. Experimental patients were also treated with dynamic splinting for first MTJ extension (60 minutes, three times per day). The dependent variable was change in active range of motion (AROM). A repeated measures analysis of variance was used with independent variables of patient categories, surgical procedure (cheilectomy vs. bunionectomy) and duration since surgery. RESULTS: There was a significant difference in change of AROM for experimental vs. control patients (P < 0.001, T = 4.224, N = 48); there was also a significant difference for patient treated within 2 months of surgery (P = 0.0221). CONCLUSIONS: Dynamic splinting was effective in reducing contracture of postoperative hallux limitus in this study; experimental patients gained a mean 250% improvement in AROM. This modality should be considered for standard of care in treating postoperative hallux limitus.

Sesamoid disorders of the first metatarsophalangeal joint.

The sesamoid complex is located centrally and plantar to the first metatarsal head, where they are imbedded within the plantar plate, which transmits 50% of body weight and more than 300% during push-off, is susceptible to numerous pathologies. These pathologies include sesamoiditis, stress fracture, avascular necrosis, osteochondral fractures, and chondromalacia, and are secondary to these large weight-bearing loads. This article discusses sesamoid conditions and their relationship with hallux limitus, and reviews the conditions that predispose the first metatarsophalangeal joint to osteoarthritic changes.

The cheilectomy and its modifications.

Hallux rigidus occurs in 10% of persons aged 20 to 34 years but in as much as 44% of people older than 80 years. Surgical intervention has been suggested for cases of hallux rigidus that have failed using conservative methods. The modified cheilectomy is considered by many the first-line treatment for this disease, given the procedure's inherent ability to eliminate degenerate bone and cartilage and decompress the intra-articular space, while sparing considerable cubic content of bone. Once the cheilectomy has been performed, there remains a sufficient volume of bone to perform a more definitive reconstruction if necessary.

Multiplanar phalangeal and metatarsal osteotomies for hallux rigidus.

Many articles have been published on the various treatments of hallux rigidus/limitus but few, if any, have focused solely on the osteotomies performed in the treatment of this disorder and provided a thorough review of the literature and critique of the procedures. Here, we describe the most commonly used, most widely accepted, and most effective osteotomies in the treatment of hallux limitus/rigidus. Along with this discussion are figures and tables to make the information accessible and user friendly. Among the procedures discussed are Keller arthroplasty, Keller interpositional arthroplasty, Bonney-Kessel, Mayo-Stone, Regnauld, Youngswick, Watermann, Watermann-Green, tricorrectional metatarsal osteotomy, sagittal V, LADO (long-arm decompression osteotomy), Drago, Lambrinudi (plantarflexory closing base wedge osteotomy), sagittal Scarf/sagittal Z, and Weil/Mau/distal oblique osteotomy.

Technique and pearls in performing the first metatarsal phalangeal joint arthrodesis.

When there is a considerable loss of first metatarsal phalangeal joint (MTPJ) motion and/or ankylosis is apparent then a joint preservation procedure may not be feasible. For end-stage degenerative change within the MTPJ, nonreducible joint incongruity, or instability of the first MTPJ, an arthrodesis can provide the most predictable and, arguably, the most definitive correction of the deformity, especially in patients with higher functional demands. This article discusses principles of techniques with an emphasis on the procedure to prepare a successful arthrodesis, and expounds on technical nuances including those associated with fixation devices.

First metatarsophalangeal joint arthrodesis: current fixation options.

This article reviews the current literature on first metatarsophalangeal joint arthrodesis rates using various forms of fixation, as well as reviewing biomechanical studies comparing the strengths of the different fixation options that are available.

Functional hallux limitus or rigidus caused by a tenodesis effect at the retrotalar pulley: description of the functional stretch test and the simple hoover cord maneuver that releases this tenodesis.

Functional hallux limitus is a loss of metatarsophalangeal joint extension during the second half of the single-support phase, when the weightbearing foot is in maximal dorsiflexion. Functionally, it constitutes a sagittal plane blockade during gait. As a result, the mechanical support and stability mechanisms of the foot are disrupted, with important consequences during gait. Functional hallux limitus is a frequent, though relatively unknown condition that clinicians may overlook when examining patients with complaints that are not limited to their feet, for they can also present other symptoms such as hip, knee and lower-back pain. The purpose of this article is to present a critical review of the literature on functional hallux limitus and to explain a previously described and simple diagnostic test (flexor hallucis longus stretch test) and a physiotherapeutic manipulation (the Hoover cord maneuver) that recovers the dorsiflexion of the hallux releasing the tenodesis effect at the retrotalar pulley, which according to our clinical experience is the main cause of functional hallux limitus. The latter, to the best of our knowledge, has never been described before.

Unilateral versus bilateral first ray surgery: a prospective study of 186 consecutive cases--patient satisfaction, cost to society, and complications.

Many studies have evaluated bilateral versus unilateral surgery in large joints, but limited research is available to compare outcomes of bilateral staged foot surgeries versus synchronous bilateral foot surgery. In total, 186 consecutive cases of first metatarsal-phalangeal (MTP) joint surgery were prospectively included in this study; 252 procedures were performed: 120 were unilateral or staged bilateral operations, and 66 were synchronous bilateral operations. Patients were evaluated at 6 and 12 weeks for specific early complications and surveyed about their return to work, activities of daily living, shoe gear requirements, satisfaction, and reasons for choosing staged or synchronous surgery. In addition, a cost analysis was performed on all surgical scenarios. Student t test showed no statistical significance between groups in all clinical settings to a 95% confidence level. Complication rates were similar and few in all situations. Patients were very satisfied when choosing bilateral synchronous surgery and would elect to repeat it the same way 97% of the time. The economic costs to the health system average 25% greater when patients undergoing first MTP joint surgery have the procedure performed one foot at a time. Combined with the time lost from work, this reveals a significant economic cost to both society and patient.

Epidemiological aspects of the surgical correction of structural forefoot pathology.

UNLABELLED: The aim of this study was to associate structural forefoot surgical correction with theories related to the etiology of structural forefoot pathology. All forefoot surgical cases performed at the Inova Fairfax Hospital Ambulatory Surgery Center over a 76-month period (January 2001 through April 2007) were reviewed and classified according to the following surgical categories: hallux abductovalgus, hallux limitus, lesser digital deformity, and combinations of these categories (N = 1684 procedures in 1592 patients). The results suggested that the etiology of lesser digital deformity was associated with the etiology of hallux abductovalgus more so than it was with hallux limitus. In fact, a patient undergoing surgical correction of a hallux abductovalgus deformity displayed 4.63 times greater odds of undergoing surgical correction of a digital deformity, or deformities, compared to a patient undergoing surgical correction of hallux limitus (OR = 4.63, 95% CI 2.81-7.71, P < .0001). Furthermore, medial (second or second and third) toe deformity correction was statistically significantly associated with hallux abductovalgus surgery (OR = 3.34, 95% CI 2.52-4.44, P < .0001), whereas lateral (fifth or fourth and fifth) toe deformity correction was statistically significantly associated with cases that did not involve hallux abductovalgus surgery (OR = 0.27, 95% CI 0.20-0.37, P < .0001). The concept of flexor hallucis longus stabilization is introduced as a possible mechanical explanation for these results. LEVEL OF EVIDENCE: 2.

Total sesamoidectomy for painful hallux rigidus: a medium-term outcome study.

BACKGROUND: The nature of the sesamoid complex in the development of hallux rigidus or limitus (HL) has been poorly characterized and the role of the sesamoids in the surgical management of this condition has not been explored. Previous surgical approaches in younger active patients unsuited to destructive procedures have been limited. MATERIALS AND METHODS: Thirty-three patients (36 procedures) were reviewed between 2 and 4 years following total sesamoidectomy for the management of hallux rigidus/limitus. The American Orthopedic Foot & Ankle Society hallux (AOFAS) clinical rating system was used to compare pre and postoperative scores. The range and quality of motion and transfer metatarsalgia were noted. The three most important patient problems and the degree to which these had been addressed by the surgery and the time to maximal improvement were noted. RESULTS: No significant functional impairment or malalignment were found. There were no instances of pain on metatarsal compression, or of transfer metatarsalgia with or without callus formation. A highly statistically significant improvement in AOFAS scores was found (p < 0.001). CONCLUSION: High levels of clinical improvement and patient satisfaction were found following total sesamoidectomy. No deleterious consequences of sesamoid removal were observed. For symptomatic patients where a joint replacement/fusion is not indicated, total sesamoidectomy was beneficial as an interim procedure, for joints with a moderate (grades 2 to 3) degree of arthrosis.

Finite element modeling of the first ray of the foot: a tool for the design of interventions.

Disorders of the first ray of the foot (defined as the hard and soft tissues of the first metatarsal, the sesamoids, and the phalanges of the great toe) are common, and therapeutic interventions to address these problems range from alterations in footwear to orthopedic surgery. Experimental verification of these procedures is often lacking, and thus, a computational modeling approach could provide a means to explore different interventional strategies. A three-dimensional finite element model of the first ray was developed for this purpose. A hexahedral mesh was constructed from magnetic resonance images of the right foot of a male subject. The soft tissue was assumed to be incompressible and hyperelastic, and the bones were modeled as rigid. Contact with friction between the foot and the floor or footwear was defined, and forces were applied to the base of the first metatarsal. Vertical force was extracted from experimental data, and a posterior force of 0.18 times the vertical force was assumed to represent loading at peak forefoot force in the late-stance phase of walking. The orientation of the model and joint configuration at that instant were obtained by minimizing the difference between model predicted and experimentally measured barefoot plantar pressures. The model were then oriented in a series of postures representative of push-off, and forces and joint moments were decreased to zero simultaneously. The pressure distribution underneath the first ray was obtained for each posture to illustrate changes under three case studies representing hallux limitus, surgical arthrodesis of the first ray, and a footwear intervention. Hallux limitus simulations showed that restriction of metatarsophalangeal joint dorsiflexion was directly related to increase and early occurrence of hallux pressures with severe immobility increasing the hallux pressures by as much as 223%. Modeling arthrodesis illustrated elevated hallux pressures when compared to barefoot and was dependent on fixation angles. One degree change in dorsiflexion and valgus fixation angles introduced approximate changes in peak hallux pressure by 95 and 22 kPa, respectively. Footwear simulations using flat insoles showed that using the given set of materials, reductions of at least 18% and 43% under metatarsal head and hallux, respectively, were possible.

Modified Youngswick procedure for hallux limitus.

Multiple surgical procedures have been described for the correction of hallux limitus deformity. We describe a new modification of the Youngswick procedure for the surgical treatment of hallux limitus. Other procedures for hallux limitus correction are also discussed. This modified Youngswick procedure will provide a new approach to treating hallux limitus secondary to metatarsus primus elevatus when shortening of the first metatarsal is not indicated.