Bertil W. Smith

Hallux Valgus and First Ray Mobility

BACKGROUND There have been few prospective studies that have documented the outcome of surgical treatment of hallux valgus deformities. The purpose of this investigation was to evaluate the effect of operative treatment of hallux valgus with use of a proximal crescentic osteotomy and distal soft-tissue repair on the first metatarsophalangeal joint. METHODS All adult patients in whom moderate or severe subluxated hallux valgus deformities had been treated with surgical repair between September 1999 and May 2002 were initially enrolled in the study. Those who had a hallux valgus deformity treated with a proximal crescentic osteotomy and distal soft-tissue reconstruction (and optional Akin phalangeal osteotomy) were then invited to return for a follow-up evaluation at a minimum of two years after surgery. Outcomes were assessed by a comparison of preoperative and postoperative pain and American Orthopaedic Foot and Ankle Society scores; objective measurements included ankle range of motion, Harris mat imprints, mobility of the first ray (assessed with use of a validated calibrated device), and radiographic angular measurements. RESULTS Of the 108 patients (127 feet), five patients (five feet) were unavailable for follow-up, leaving 103 patients (122 feet) with a diagnosis of moderate or severe primary hallux valgus who returned for the final evaluation. The mean duration of follow-up after the surgical repair was twenty-seven months. The mean pain score improved from 6.5 points preoperatively to 1.1 points following surgery. The mean American Orthopaedic Foot and Ankle Society score improved from 57 points preoperatively to 91 points postoperatively. One hundred and fourteen feet (93%) were rated as having good or excellent results following surgery. Twenty-three feet demonstrated increased mobility of the first ray prior to surgery, and only two feet did so following the bunion surgery. The mean hallux valgus angle diminished from 30 degrees preoperatively to 10 degrees postoperatively, and the mean first-second intermetatarsal angle decreased from 14.5 degrees preoperatively to 5.4 degrees postoperatively. Plantar gapping at the first metatarsocuneiform joint was observed in the preoperative weight-bearing lateral radiographs of twenty-eight (23%) of 122 feet, and it had resolved in one-third (nine) of them after hallux valgus correction. Complications included recurrence in six feet. First ray mobility was not associated with plantar gapping. There was a correlation between preoperative mobility of the first ray and the preoperative hallux valgus (r = 0.178) and the first-second intermetatarsal angles (r = 0.181). No correlation was detected between restricted ankle dorsiflexion and the magnitude of the preoperative hallux valgus deformity, the postoperative hallux valgus deformity, or the magnitude of hallux valgus correction. CONCLUSIONS A proximal crescentic osteotomy of the first metatarsal combined with distal soft-tissue realignment should be considered in the surgical management of moderate and severe subluxated hallux valgus deformities. First ray mobility was routinely reduced to a normal level without the need for an arthrodesis of the metatarsocuneiform joint. Plantar gapping is not a reliable radiographic indication of hypermobility of the first ray in the sagittal plane.

Metatarsophalangeal joint pathology in crossover second toe deformity: a cadaveric study.

Background: Ligamentous and capsular insufficiency of the second metatarsophalangeal joint has been surgically treated for over two decades, mainly with indirect surgical repairs, which stabilize adjacent soft tissue and shorten or decompress the osseous structures. While ligamentous insufficiency has been described and recognized, degeneration of the plantar plate and tears of the capsule have rarely been documented. The purpose of this study was to document and describe the presence and pattern of plantar plate tears in specimens with crossover second toe deformities, and based on this, to develop an anatomical grading system to assist in the assessment and treatment of this condition. Methods: Sixteen below-knee cadaveric specimens with a clinical diagnosis of a second crossover toe deformity were examined, and dissected by removing the metatarsal head. The pathologic findings of plantar plate and capsular pathology, as well as ligamentous disruption, were observed and recorded. Demographics of the specimens were recorded, and simulated weightbearing radiographs were obtained prior to dissection so that pertinent angular measurements could be obtained. Results: Demographics demonstrated a high percentage of female specimens, and a typically older population that has been reported for this condition. Radiographic findings documented a high percentage of hallux valgus and hallux rigidus deformities. The MTP-2 and MTP-3 angles were divergent consistent with a crossover toe deformity. We consistently found transverse tears in the plantar plate region immediately proximal to the capsular insertion on the base of the proximal phalanx. With increasing deformity, wider distal transverse tears extending from lateral to medial were found. Midsubstance tears, collateral ligament tears, and complete disruption of the plantar plate were found in more severe deformities. Conclusion: In this largest series of cadaveric dissections of crossover second toe deformities, we describe the types and extent of plantar plate tears associated with increasing deformity of the second ray. We present, based on these findings, an anatomic grading system to describe the progressive anatomic changes in the plantar plate.

Disorders of the lesser toes.

Lesser toe disorders are an often under-appreciated source of pain and disability in athletes. Patients may have significant symptoms from corns, hammertoe and mallet toe deformities, and metatarsalgia resulting from neuromas and metatarsophalangeal joint instability. Although patients may present with vague symptoms, a careful history and physical examination will point a clinician to an accurate diagnosis. Treatment of these lesser toe disorders is straightforward and leads to predictably good results.

Footprint of the Lateral Ligament Complex of the Ankle

Background: We describe the topographic anatomy of the lateral ligament complex of the ankle using 3-dimensional (3D) computed tomography (CT) imaging. Methods: Dissection of the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL) was performed on 8 unpaired fresh-frozen cadaver feet. Ligaments were sharply dissected from bone, and the footprint was outlined with radio-opaque paint. The specimen underwent a 0.625-mm slice CT scan of the ankle with 3D reconstructions. Software was used to determine the surface area of the ligament footprint as well as measure the distance from the peroneal tubercle to the center of the CFL footprint. Data are presented as mean ± standard error. Results: Six specimens had a bifid ATFL. Seven ankles had a bifid ATFL footprint on the talus. All specimens had intact CFL fibers. The intact superior and inferior limbs of the ATFL measured 19.7 ± 1.2 mm and 16.7 ± 1.1 mm. The CFL measured 24.8 ± 2.4 mm. The area of the footprints of the superior ATFL and inferior ATFL on the talus measured 1.5 ± 0.26 cm2 and 0.90 ± 0.07 cm2. The CFL and ATFL origins on the fibula were continuous and measured 3.48 ± 0.39 cm2. The CFL insertion on the calcaneus measured 2.68 ± 0.20 cm2. The CFL was found 27.1 ± 1.0 mm posterior and superior from the peroneal tubercle. Conclusions: In presumably uninjured specimens, both the ATFL and its footprint on the talus were bifid. The CFL and ATFL origins have a single confluent footprint on the anterior border of the distal fibula. The CFL footprint on the calcaneus is almost 3 cm posterior and superior to the peroneal tubercle. Clinical Relevance: This study may assist surgeons in anatomically reconstructing the lateral ligament complex of the ankle.

The first metatarsocuneiform joint, hypermobility, and hallux valgus: what does it all mean?

The etiology and treatment of the hallux valgus deformity has long been a subject of controversy. Early reports focused on increased first metatarsocuneiform joint mobility as the primary cause of the deformity. While this theory was widely accepted, little evidence was offered in its support. Recent reports have provided objective evidence calling into question the notion of hypermobility. While flexibility in the first metatarsocuneiform joint is necessary for hallux valgus to develop, increased mobility is the result rather than the cause of the deformity.

The Evaluation of the Healing Rate of Subtalar Arthrodeses, Part 2: The Effect of Low-Intensity Ultrasound Stimulation:

Background: Arthrodeses of hindfoot joints is commonly used to treat a multitude of painful conditions and deformity. Use of adjuvant low-intensity ultrasound bone stimulation has demonstrated promising results in the treatment of acute fractures and fracture nonunions. The purpose of this 12-month prospective study was to evaluate the healing rate and clinical results of patients undergoing primary subtalar arthrodeses with adjuvant low-intensity ultrasound bone stimulation. Materials and Methods: Fifteen consecutive patients participated in the study. Routine radiographs and CT scans were obtained, and clinical outcomes gathered. The clinical and radiographic data were compared to a similar cohort of patients previously reported on that had not received ultrasound bone stimulation. Results: The patients who received ultrasound bone stimulation showed a statistically significant faster healing rate on plain radiographs at 9 weeks (p = 0.034) and CT scan at 12 weeks (p = 0.017). A 100% fusion rate was noted. The American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot score was also improved at 12 months postoperatively, a finding that was statistically significant (p = 0.026). Conclusion: This is the first paper, to our knowledge, to prospectively evaluate ultrasound bone stimulation in primary hindfoot arthrodesis patients. We were able to show significantly improved radiographic as well as clinical outcomes compared with a similar cohort of patients who did not receive adjuvant ultrasound stimulation. We believe that low-intensity ultrasound bone stimulation is indicated in primary hindfoot fusions, particularly in those patients at higher risk for nonunion. Level of Evidence: II, Prospective Comparative Study

Treatment of Hallux Valgus with Increased Distal Metatarsal Articular Angle: Use of Double and Triple Osteotomies

The treatment of the congruent hallux valgus deformity requires special consideration for a successful outcome to be obtained. The distal metatarsal articular angle is of critical importance in this deformity. The goal of correction is to achieve a realigned first ray and preserve the congruent first metatarsophalangeal articulation. In patients with an increased distal metatarsal articular angle and congruent joint, the use of double and triple first ray osteotomies must be used to achieve satisfactory correction.

First metatarsocuneiform joint mobility: Radiographic, anatomic, and clinical characteristics of the articular surface

Background: The first metatarsocuneiform joint is involved in first ray biomechanics and related forefoot pathology. The purpose of this study was to evaluate the first metatarsocuneiform joint radiographic findings in relation to angular position of the radiographic beam, and to assess the joint mobility as it relates to the anatomic orientation of the facets on both radiographic imaging and gross anatomic dissection. Methods: Thirty-nine cadaveric lower extremity limbs were stratified as normal, mild, moderate, or severe hallux valgus deformity. Mobility of the first metatarsocuneiform joint for each specimen was assessed using the Klaue device. The medial inclination angle (obliquity) of the first metatarsocuneiform joint was determined on both 10-degree and 20-degree anteroposterior radiographs. The lateral inclination angle of both the dorsal and plantar facets was determined on lateral radiographs. Each specimen was then dissected to directly inspect the metatarsocuneiform joint. Results: The metatarsocuneiform joint mean height was 28.3 mm and the mean width was 13.1 mm. Twenty-three feet demonstrated a continuous cartilaginous surface, 15 feet demonstrated a bilobed cartilaginous surface, and 1 foot demonstrated completely separated facets. Dorsal facets were curved in 37 specimens and flat 2 specimens. Plantar facets were flat in 30 specimens and curved in 9 specimens. The medial inclination angle measured 15.8 degrees on the 10-degree radiograph and 2.6 degrees on the 20-degree radiograph. We were unable to establish any correlations of metatarsocuneiform joint angles or facet contour with mobility measured by the Klaue device. Conclusions: The metatarsocuneiform joint has a height to width ratio of nearly 2:1. Continuous and bilobed facets are both very common anatomic variants. The contour of the dorsal facet was predominantly curved and the contour of the plantar facet was predominantly flat. First metatarsocuneiform joint mobility does not appear to be dependent on the contour of the facets or the degree of medial inclination of the joint. Clinical Relevance: Anatomic and radiographic findings with regard to mobility of the first metatarsocuneiform joint may assist the surgeon in interpreting the joint’s relationship to hallux valgus deformity and to aid in clinical decision making. Our findings suggest that radiographic interpretation of medial inclination is unreliable and should not be used to determine the appropriateness of specific operative procedures.

Reconstruction of a Chronic Extensor Hallucis Longus Tendon Laceration With a Gracilis Tendon Autograft

Extensor hallucis longus tendon injuries are uncommon, representing < 2% of tendon injuries. Lacerations are more common than spontaneous ruptures, and if neglected are often difficult to primarily repair because of tendon retraction and scarring. Few reports address the operative treatment of chronic extensor hallucis longus tendon injuries. To our knowledge the use of a gracilis tendon autograft has not been reported. We describe the use of this free tendon autograft with a hallux interphalangeal joint arthrodesis in one patient.

Comparison of Radiographic and Anatomic Distal Metatarsal Articular Angle in Cadaver Feet

Background: A few studies report correlations between radiographic and anatomic measurements of the distal metatarsal articular angle (DMAA). However, little is known about how the DMAA correlates with the hallux valgus angle (HVA) and with anatomic and clinical radiographic measurements. Methods: We dissected, measured, and radiographed 39 cadaveric feet for evidence of hallux valgus and the DMAA. We then correlated these values with paired clinical radiographic measurements made by physician evaluators. Results: Physician measurement of DMAA and anatomic measurement of DMAA were significantly correlated with a mean r = 0.64 (evaluator range, 0.44-0.66). Pairwise correlation between physician evaluators ranged from r = 0.63 to 0.84. Sixty-six percent of physician-measured DMAAs were within 5 degrees of anatomic DMAA. Conclusion: The percentage of radiographic DMAAs that were within 5 degrees of anatomic DMAAs was only 66%. Additionally, the DMAA was increased in the specimens with moderate and severe hallux valgus compared with those with normal or mild hallux valgus angles. Clinical Relevance: The DMAA is an important consideration in patients with hallux valgus. While it is less reliable than other radiographic measures, it was correlated to deformity severity in specimen with hallux valgus.