Brett R. Grebing

Comprehensive Reconstruction of the Lateral Ankle for Chronic Instability Using a Free Gracilis Graft

Purpose: The purpose of this retrospective study was to assess the results of a novel surgical technique for the treatment of chronic lateral ankle instability using both a direct repair of the anterior talofibular ligament and a free gracilis tendon transfer to reconstruct anatomically the anterior talofibular and calcaneofibular ligaments. Methods: Between December 1998 and February 2002, 28 patients (29 ankles) underwent an anatomic reconstruction of the lateral ankle ligaments for chronic ankle instability. Patients returned for a clinical and radiologic follow-up evaluation at an average of 23 months following surgery (range, 12–52 months). Outcomes were assessed by comparison of preoperative and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) scores and visual analog pain scores as well as a postoperative Karlsson score. A subjective self-assessment rating was also obtained. All patients underwent preoperative and postoperative radiographic assessment including talar tilt and anterior drawer stress radiographs. Results: Twenty-eight patients (29 ankles) (100%) returned for final evaluation. Good or excellent outcome was noted on patient subjective self-assessment, pain scores, AOFAS, and Karlsson scores at final follow-up in all patients. Ankle range of motion was not affected by lateral ankle reconstruction. The talar tilt was reduced from a mean of 13° to 3° (p < .0001) and the anterior drawer was reduced from a mean of 10 mm to 5 mm (p < .0001) by the lateral ankle ligamentous reconstruction. Conclusion: In the present study, lateral ankle reconstruction with a direct anterior talofibular ligament repair and free gracilis tendon graft augmentation resulted in a high percentage of successful results, excellent ankle stability with a minimal loss of ankle or hindfoot motion, and marked reduction of pain at an average follow-up of almost 2 years.

Arthrodesis of the First Metatarsophalangeal Joint for Idiopathic Hallux Valgus: Intermediate Results

Background: Followup studies documenting the outcome of primary metatarsophalangeal (MTP) joint arthrodesis for treatment of hallux valgus deformities are rare. The purpose of this report was to evaluate the results of first MTP joint arthrodesis as treatment for moderate and severe hallux valgus deformities over a 22-year period in a single surgeons practice. Methods: All living patients treated between 1979 and 2001, for moderate and severe idiopathic hallux valgus deformities with first MTP joint arthrodesis were contacted and asked to return for a followup examination. Outcomes were assessed by comparing preoperative and postoperative pain, function, and radiographic appearance. First ray mobility and ligamentous laxity also were assessed postoperatively.Results: Eighteen of 21 of the first MTP joints had successfully fused with the primary procedure at an average followup of 8.2 years (range 24 to 271 months). The time to union averaged 10 (range 7 to 15) weeks. Two of the three nonunions, both in the same patient, were asymptomatic and were not revised. One required a revision to achieve fusion. The average corrections in the hallux valgus angle and 1–2 intermetatarsal (IM) angle were 21 degrees and 6 degrees, respectively, and the average postoperative dorsiflexion angle was 22 degrees. Subjective satisfaction was rated as excellent in seventeen of 21 cases (80%) and good in the remaining four (20%). There was significant reduction in postoperative pain (p < 0.001), complete resolution of lateral metatarsalgia, and the postoperative American Orthopaedic Foot and Ankle Society (AOFAS) scores averaged 84 (range 72 to 90) at final followup. Major activity restrictions after surgery were uncommon, and all patients were able to wear conventional or comfort shoes. Interphalangeal (IP) joint arthritis progressed in seven of 21 feet (33%), but all of these changes were mild. Conclusions: In the present study, arthrodesis of the first MTP joint for idiopathic hallux valgus resulted in a high percentage of successful results at an average followup of over 8 years.

Hallux Valgus and First Ray Mobility: A Cadaveric Study

Background: Several studies have demonstrated that patients with hallux valgus (HV) deformities have increased first ray sagittal mobility. However, the change in mobility that occurs after surgical correction of HV deformities has not been extensively evaluated. This study was done to determine if surgical realignment of the first ray in cadaver specimens with a proximal crescentic osteotomy and distal soft tissue reconstruction (DSTR) would reduce the first ray sagittal motion as measured with an external-type micrometer (the Klaue device). Methods: Twelve fresh-frozen below-knee cadaver specimens with an HV deformity (HV angle > 15 degrees, 1-2 IM angle > 9 degrees) were used for the study. Standardized simulated weightbearing radiographs were obtained before and after the surgical correction of the deformity. The first ray sagittal motion was measured with an external micrometer (Klaue device) before correction of the HV deformity and after the procedure. All specimens had correction of the hallux valgus deformity with a DSTR and proximal crescentic osteotomy. Internal fixation was applied to secure the osteotomy site. Results: The HV angle was corrected from a mean of 28.6 degrees to a mean of 11.0 degrees. The 1-2 IM angle was corrected from a mean of 12.9 degrees to a mean of 6.8 degrees. The average preoperative first ray sagittal motion was 11.0 mm (range, 8.5 mm to 13.5 mm). After the surgical repair, the mean sagittal first ray motion was significantly decreased (p <.0005) to a mean of 5.2 mm (range, 3.5 mm to 7.5 mm). Conclusion: After correction of HV deformities with a DSTR and a proximal crescentic osteotomy, first ray mobility in cadaver specimens was significantly reduced. The stabilization of first ray mobility that occurred immediately after surgical correction despite leaving the capsule of the first metatarsocuneiform (MC) joint undisturbed suggests that extrinsic anatomic features may play a role in first ray mobility. Additionally, stability of the first ray may be restored with a bunion procedure that does not sacrifice the first MC joint.

Evaluation of Morton's Theory of Second Metatarsal Hypertrophy

BACKGROUND Originally introduced by Morton, the concept of hypertrophy of the medial cortex and the entire shaft of the second metatarsal as an objective sign of increased mobility of the first ray has not been subjected to much scrutiny. The goal of the current study was to assess the clinical relevance and reliability of radiographic measures of hypertrophy of the second metatarsal in relation to mobility of the first ray, pes planus, and tightness of the gastrocnemiussoleus in both control subjects and patients with diagnosed disorders of the forefoot. METHODS Four study groups of forty-three subjects each were evaluated. The cohort included an asymptomatic control group as well as three groups made up of patients with symptoms and a diagnosis of hallux valgus, hallux rigidus, or interdigital neuroma. Mobility of the first ray (as measured with a device and method described by Klaue et al.), arch height, and ankle dorsiflexion were measured on physical examination. Plain weight-bearing radiographs and previously established equations were used to determine hypertrophy and the length of the second metatarsal, and the hallux valgus and first-second intermetatarsal angles were measured on plain radiographs as well. RESULTS There was no significant difference between the control and symptomatic groups with regard to the values for hypertrophy of the second metatarsal. The patients with hallux valgus deformity had significantly greater mobility of the first ray (p < 0.001) compared with the controls. No correlation was found between values for hypertrophy of the second metatarsal and mobility of the first ray, the length of the first metatarsal, pes planus, or restricted ankle dorsiflexion. No correlation was found between mobility of the first ray and either pes planus or restricted ankle dorsiflexion. A weak correlation (r = 0.4) was noted between increased mobility of the first ray and the hallux valgus angle. CONCLUSIONS Our findings do not support Mortons concept that medial cortical hypertrophy and increased shaft width of the second metatarsal are associated with increased mobility of the first ray or relative shortness of the first metatarsal. In addition, hypertrophy of the second metatarsal was not associated with either pes planus or restricted ankle dorsiflexion. We found the practice of using hypertrophy of the second metatarsal as an indicator of mobility of the first ray to be unreliable, and thus we consider it to be an inappropriate indication for arthrodesis of the first metatarsocuneiform joint in the treatment of hallux valgus deformity.

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.

The effect of ankle position on the exam for first ray mobility

Purpose: The clinical assessment of first ray motion in the sagittal plane, as originally described by Morton, is difficult to quantify. Different reports have shown inconsistent values and variability between the manual exam and examination using an external measuring device. The authors hypothesize that when performing a manual examination for evidence of increased first ray motion, the magnitude of first ray mobility varies as the position of ankle dorsiflexion/plantarflexion varies. Methods: Using an external caliper (a modified Klaue device), the authors quantified first ray motion in reference to variable ankle positions in a group of normal patients, a group of patients with untreated moderate and severe hallux valgus, a group who had undergone a successful metatarsophalangeal joint arthrodesis for hallux valgus, and a small group who had previously undergone a plantar fasciectomy. A total of 119 feet (109 patients) were measured. In addition to first ray motion, radiographic data were compared between groups. Results: With the ankle in the neutral dorsiflexion position, the mean first ray motion was 4.9 mm for the control group, 7.0 mm for the hallux valgus group, 4.4 mm for the metatarsophalangeal fusion group, and 7.7 mm for the plantar fasciectomy group. There was a significant decrease (p <.05) in first ray motion when the ankle was moved to the dorsiflexed position for all four groups. There was a significant increase in first ray motion when the ankle was moved to the plantarflexed position (p < .01) for all groups except the plantar fasciectomy group. No significant difference in first ray motion was observed for the plantar fasciectomy group between the neutral and plantarflexed ankle positions (p < .05). Conclusion: The exam for first ray mobility is influenced by the position of the ankle and may explain the discrepancy between the manual exam and measurement with an external device. Recommendations for the manual exam of first ray mobility are given.

The validity and reliability of the Klaue device.

Background: Excessive first ray mobility has been implicated as the cause of many forefoot abnormalities. The association between hypermobility and forefoot pathology is controversial, and this is largely related to the difficulty in quantifying first ray motion. Manual examinations have been shown to be unreliable. Klaue et al. developed a device consisting of a modified ankle-foot orthosis with an attached micrometer to objectively measure first ray mobility. The purpose of this study was to evaluate the validity and reliability of this device. Methods: Sixteen fresh-frozen, below-knee amputation specimens with hallux valgus were used for the study. The study was divided into two parts. Part I was an analysis of the validity of the Klaue device; first ray dorsal displacement was measured on lateral radiographs following manual manipulation, and values were statistically compared to the Klaue device measurements. Part II of the study was an evaluation of intraobserver and interobserver agreement. Two clinicians used the Klaue device on each of the cadaver limbs, and values of first ray sagittal mobility were recorded and compared. Results: The mean value of first ray mobility measured with the Klaue device was 7.5 mm and the average displacement measured from the lateral radiographs was 7.4 mm. Paired t-testing showed no significant difference between the Klaue and radiographic measurements (p = 0.83). The mean first ray mobility by examiners 1 and 2 with the Klaue device were identical (10.5 mm), and statistical analysis showed no significant interobserver or intraobserver differences. Conclusions: The results confirm the validity of the Klaue device and limited variability of measurements between experienced users.

A Comparison of Device Measures of Dorsal First Ray Mobility

Background: Devices built by Glasoe and Klaue have been used in several studies to measure first ray mobility. Both devices measure sagittal motion of the first ray in a dorsal direction. The primary difference in the devices is the method of the load imposed. This study investigates whether first ray mobility measured with the Glasoe device is similar to the amount of mobility measured with the Klaue device. Methods: Using the devices described by Glasoe and Klaue, dorsal first ray mobility was measured in 39 patients who had foot and ankle problems. Paired t-tests were computed to assess for differences between device measures of dorsal mobility. Intraclass correlation coefficient (ICC) and absolute difference values were computed to further assess the agreement in measures. Results: Dorsal mobility measured with the Glasoe device averaged 4.9 mm (1.8 to 9.3 mm). Dorsal mobility measured with the Klaue device averaged 5.2 mm (2.5 to 8.5 mm). Paired t-tests (p = 0.12) revealed no significant difference in measures. An ICC of 0.70 and a mean absolute difference of 0.9 mm (SD 0.8) were found between the two clinical measures further suggesting agreement. Conclusion: Results indicated that the two devices possess similar diagnostic accuracy in the measurement of dorsal first ray mobility.

First Metatarsophalangeal Joint Motion After Hallux Valgus Correction: A Cadaver Study

Background: Surgical correction of hallux valgus deformities often results in decreased first metatarsophalangeal joint (MTPJ) range of motion. Loss of motion has been shown to affect patient satisfaction. The purpose of this study was to evaluate the immediate change in MTPJ range of motion that occurs after a distal soft-tissue reconstruction (DSTR) and proximal metatarsal osteotomy (PMO). Methods: DSTR and PMO were done on 16 below-knee cadaver specimens with clinically apparent hallux valgus deformities. Two examiners assessed preoperative and postoperative dorsiflexion (DF), plantarflexion (PF), and the total range of motion of the first MTPJ. The hallux valgus angle (HVA) and 1–2 intermetatarsal angle (1–2 IMA) were measured on simulated weightbearing radiographs before and after operative correction. Changes in motion were analyzed and correlated with the angular measurements. Results: The mean total range of motion preoperatively was 85.4 degrees (DF 70.5 degrees, PF 14.9 degrees) and significantly decreased (p < 0.005) 23.2 degrees to a postoperative value of 62.2 degrees (DF 47.9 degrees, PF 14.3 degrees). There was a significant (p < 0.005) decrease in DF (22.6 degrees) with the operative correction, but the loss of PF (0.6 degrees) was not significant (p = 0.7). There was no correlation between the magnitude of correction (HVA, 1–2 IMA) and the change in PF, DF, or total motion. Conclusions: Correction of a hallux valgus deformity with a DSTR and PMO is associated with an immediate loss of range of motion that primarily affects the DF arc of the first MTPJ. The selective loss of DF may be related to a nonisometric capsular repair or tight intrinsic musculature, although there was no correlation with the magnitude of angular correction. The immediate decrease in motion observed in this cadaver study underscores the importance of early postoperative joint mobilization to prevent long-term stiffness after bunion surgery.

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.