Cheilectomy of the big toe is offered in the early stages of arthritis affecting the big toe MTPJ, with the understanding that if it fails then a more definitive surgical treatment (e.g. MTPJ fusion or replacement) may be required. When considering treatment options, patients want to know how long will a cheilectomy procedure last. There is limited evidence available about the long term results after cheliectomy, particularly with regards to time to revision surgery. Our aim was to establish the long-term results of cheilectomy with regards to revision surgery and patient-satisfaction over a period of 10 years. A retrospective review of big toe MTPJ cheilectomies was performed at our institute from 2002 to 2012. The patients were identified using a combination of medical coding system, clinical records, operative log, and radiographs. A systemic review of chielectomy by Roukis (2010) was identified as the clinical standard and revision surgery after cheilectomy, average time to revision and patient satisfaction was assessed. 204 cheilectomies were identified in 192 patients over a period of 10 years. Majority had grade 2 OA (n = 106, 54 %) with grade 3 (n= 65, 33 %) and grade 1 (n= 24, 12 %). The mean follow-up was 4 yrs. (range 6 m to 9 yrs. and 8 m). The overall revision rate to any surgery was 4.4% (n=9), and revision to MTPJ arthrodesis was 3.4% (n =7). The average time to revision was 1 yr. 4 m. 101 patients (55%) were contactable over the phone, and majority (82 %) of them were satisfied with the clinical outcome. This study shows slightly better overall revision rate (4.4% vs. 8.8%), with revision to arthrodesis being similar (3.4% vs. 3.25%) as compared to the clinical standard. It also suggests that cheilectomy of the big toe can last for a minimum of up to 4 years in 95 % of cases. The 5 % of cases that may require revision surgery are likely to present within the first 2 years. This information is very useful to a patient who wants to know “how long will my cheilectomy last?” whilst making an informed choice

Background. There is a general assumption amongst many patients – and some Surgeons- that 1. Metatarsophalangeal Joint Arthrodesis “in neutral plantigrade position” will postoperatively restrict the choice of shoes and heels in particular. To our knowledge no studies have been carried out to assess this further. Methods. A review of a single Surgeon's series of 25 patients and Radiographs following neutral 1.MTPJ Arthrodesis after 14 – 38 months follow up to assess the type of shoe and height of heel comfortably worn. Results. Out of 18 women whose 1. MTPJ was fused in neutral 12 were able to wear at least a 2 inch (5 cm) heel comfortably the remaining 6 wore mainly flat shoes because of contralateral disease or unrelated reasons. All men interviewed wore a wide range of different comfortable shoes. Conclusion. 1. MTPJ Arthrodesis in neutral does not restrict the choice of shoes/heels postoperatively. Our findings might further strengthen the argument in favour of Arthrodesis vs Joint replacement

Introduction. Surgical treatment options for osteoarthritis of the first MTPJ include fusion, excision arthroplasty, interposition arthroplasty and replacement arthroplasty. . 1. Arthroplasty of the first MTPJ is not a treatment modality that is, as yet, widely accepted. . 2,3. although early results are promising. The Toefit-plus (tm) first MTP joint arthroplasty is an uncemented modular hemi or total joint replacement. The aim of this study was to look at the short to medium term outcome of the Toefit-plus(tm) system, performed by a single surgeon in a district general hospital. Methods. This was a retrospective study. Information was obtained from a combination of theatre logs and the operating surgeon's records. Any patient who had undergone Toefit -plus(tm) first MTP joint replacement was included. The demographic information was collated and the patients were scored using the AOFAS-IP scoring system and a VAS for pain. Results. 16 patient were identified with a total of 20 Toefit-plus(tm) arthroplasties. The vast majority of the patients were female 15/16 (94%) and the average age of the patients was 57.5 years (33-63 years). The average time at follow up was 16.55 months (2-45). No revision procedures had been performed. Conclusions. In our small study of a mainly female population the Toefit-Plus(tm) first MTP joint replacement results in a good functional outcome in the short term. Ongoing assessment will be required to investigate whether this benefit is maintained in the long term

Numerous procedures have been reported for the hallux valgus correction of the great toe. Scarf osteotomy is a versatile osteotomy to correct varying degrees of mild to moderate hallux valgus deformity. It can also be used for lengthening of the 1st ray as a revision procedure to treat metatarsalgia in patients who had previous shortening osteotomy. We wish to report a patient who had lengthening SCARF osteotomy for the metatarsalgia following previous hallux valgus correction and developed arthritis of the 1st MTPJ in a short term which required fusion. A 49 year old female patient was seen with pain and tenderness over the heads of the 2nd and3rd metatarsal of the right foot. She had hallux valgus correction 10years ago with a shortening osteotomy of the 1st metatarsal. She developed metatarsalgia which failed to conservative management. She had a lengthening SCARF osteotomy for the metatarsalgia in 2004. She had good symptomatic relief for two years and then started having pain over the 1st MTPJ. On examination she had limited movements of the 1st MTPJ and tenderness over the dorsolateral aspects of the 1st MTPJ suggestive of arthritis. Radiographs of the foot showed healed osteotomy with no evidence of AVN of the 1st MT head but features suggestive of osteoarthritis. She had fusion of the 1st MTPJ performed in 2008 for the arthritis following which symptoms resolved. This case highlights that arthritis of the 1st MTPJ can occur in the absence of an AVN of the metatarsal head and patients need to be warned of this potential complaining when having the lengthening SCARF osteotomy for metatarsalgia following a previous shortening osteotomy of the 1st ray

Aims. The Cartiva synthetic cartilage implant (SCI) entered mainstream use in the management of first metatarsophalangeal joint (MTPJ) arthritis following the positive results of large trials in 2016. Limited information is available on the longer-term outcomes of this implant within the literature, particularly when independent from the originator. This single-centre cohort study investigates the efficacy of the Cartiva SCI at up to five years. Methods. First MTPJ arthritis was radiologically graded according to the Hattrup and Johnson (HJ) classification. Preoperative and sequential postoperative patient-reported outcome measures (PROMs) were evaluated using the Manchester-Oxford Foot Questionnaire (MOXFQ), and the activities of daily living (ADL) sub-section of the Foot and Ankle Ability Measure (FAAM). Results. Patients were followed up for a mean of 66 months (SD 7.1). Of an initial 66 cases, 16 did not return PROM questionnaires. A total of six failures were noted, with survival of 82%. Overall, significant improvement in both objective scores (MOXFQ and FAAM ADL) was maintained versus preoperatively: 18.2 versus 58.0 (p > 0.001) and 86.2 versus 41.1 (p > 0.001), respectively. The improvement was noted to be less pronounced in males. Subjective scores had deteriorated since early follow-up, with an interval decrease in patient satisfaction from 89% to 68%. Furthermore, a subset of cases demonstrated clinically important interval deterioration in objective scores. However, no specific patient factors were found to be associated with outcomes following analysis. Conclusion. This study represents the longest-term independent follow-up in the literature. It shows reassuring mid-term efficacy of the Cartiva SCI with better-than-expected survival. However, deterioration in scores for a subset of patients and lower satisfaction may predict ongoing failure in this group of patients. Additionally, males were noted to have a lower degree of improvement in scores than females. As such, ongoing observation of the SCI to assess durability and survivability, and identify predictive factors, is key to improving patient selection. Cite this article: Bone Jt Open 2024;5(9):799–805

Introduction. There are a number of options available for surgical management of hallux rigidus. Ceramic implants of the first metatarsophalangeal joint (MTPJ) have been available for years; however there are no published long-term results existing. Methods. We performed a retrospective review of all consecutive first MTPJ replacements carried out for later stage hallux rigidus using second generation MOJE ceramic implant with press-fit design. Two specialised foot and ankle surgeons performed these operations at a tertiary referral centre. Patient underwent regular follow ups including clinical review, functional scoring (AOFAS and FFI) and assessment of radiographs. Kaplan Meyer Survival analysis was performed. Results. Our study included 31 prostheses in 24 female patients. Average age at operation was 55.3 years and average follow up time was 80 months. No patients were lost until follow up. Complications included one case of superficial infection and five cases of revision, reasons being fracture of the prostheses (1), unexplained pain (1), subluxation (1) and loosening/sinkage of the implant (2). Prosthesis survival rate was 85.2% at seven years. Assessment of the radiographs showed considerable sinkage of the prosthesis in 43%, tilting in 33% and loosening of the implant in 40.9%. Average postoperative AOFAS score was 71.6 and the average FFI was 27.7. 84% of the patients were satisfied with the results of their operation. Conclusion. Surgery has failed to preserve the function and increase the range of movement in most cases in the long duration. From the patients perspective however the satisfaction with the procedure suggests a success of the implant. Due to poor radiological results and high revision rate we do not recommend the routine use of this prosthesis and all patients that have this type of prosthesis need regular follow up consultations at least yearly with radiographs to assess the position of the implant

We present a case control comparison between two methods of fixation for 1st metatarsophalangeal (MTPJ) fusion. From 2007–2008 sixty patients were treated with either 4.0mm ACE (De Puy) screws or a Hallu-fix (Integra LifeSciences) plate fixation. We found no difference between the two groups in regard to age, ASA grade, smoking status and non-steroidal antiinflammatory use but there was a statistically significant difference in union rates. In the Hallu-fix group, nine patients went on to develop a non-union whereas one patient developed a non-union in the ACE screw fixation group, p = 0.01. Whilst there may be perceived advantages with the Hallu-fix system in regard to the accuracy of reduction, from our results we caution against it’s use, and have found a better outcome with cheaper 4.0mm ACE screws.

Arthrodesis of the first metatarsophalangeal joint (MTPJ) is the most reliable surgical option, for hallux rigidus from end-stage osteoarthritis. The aim of the study was to compare the functional outcomes of memory nickel-titanium staples versus a compression plate with a cross screw construct for first MTPJ arthrodesis using the Manchester–Oxford Foot Questionnaire (MOXFQ). Patients who underwent MTPJ arthrodesis using either memory nickel-titanium staples or a compression plate with a cross screw construct were identified from the surgical lists of two orthopaedic consultants. Pre and post-operative MOXFQ questionnaire, a validated patient-reported outcome measure, was administered, and responses were analysed to derive the MOXFQ summary index. The study included 38 patients (staple group N=12 and plate and cross screw group N=26). 23 patients were female and 15 were male. Mean age was 64.8 years (SD 9.02; 40 to 82). Initial analysis showed no significant difference in preoperative MOXFQ scores between the groups (p = 0.04). Postoperatively, the staple group exhibited a mean improvement of 36.17, surpassing the plate group's mean improvement of 23. Paired t-test analysis revealed a statistically significant difference (t-score= 2.5, p = 0.008), favouring the use of staples. The findings indicate that the use of staples in MTPJ arthrodesis resulted in a significantly greater improvement in MOXFQ scores compared to plates. Further research is needed to explore the underlying factors contributing to this difference and to evaluate long-term effects on patient outcomes

MTPJ instability is very common yet there is no consensus of best surgical technique to repair it. The current techniques range from extensive release, K-wire fixation or plantar plate repair, which requires release of remaining intact plantar plate and all collaterals. Such varieties reflect a controversy regarding its aetiology. The aim of this study was to assess how much each structure contributes towards the stability of MTPJ and describing a simple technique designed by the senior author that can anatomically reconstruct all contributing structures to the pathology. Eleven cadaveric toes in two groups (five in group 1 and six in group 2) were included. Dorsal displacement (drawer test) was used to measure instability in an intact MTPJ followed by two different series of sequential sectioning of each part of collateral ligament (PCL and ACL) and part or complete plantar plate. Group 1 result showed that after incising PCL dorsal displacement was 0.51mm, PCL+ACL was 0.8mm and PCL+ACL+50% plantar plate was 2.39mm. Group 2 results showed that after incising 50% plantar plate dorsal displacement was 0.48mm, after full plantar plate 0.62mm, plantar plate +PCL was 0.74mm and plantar plate +PCL+ACL was 1.06mm. To produce significant instability, both collaterals on one side with combination of 50% plantar plate tear was needed. An isolated 50% tear of plantar plate caused less displacement of MTPJ compared to isolated collaterals. PCL contributed more towards the stability of MTPJ when the plantar plate was intact. Whereas, ACL contributed more stability when plantar plate was sectioned. The current practice of releasing the collaterals to gain access for repairing plantar plate by indirect method should be re-evaluated. A new technique of proximal tenotomy of extensor digitorum brevis tendon looped around the transverse ligament and attached to the neck of metatarsal reconstructs both structures (plantar plate and collaterals)

Background. Severe hallux rigidus can be treated with total or hemi arthroplasty to preserve motion in the 1st metatarsophalangeal joint (MTPJ). Decreased dorsiflexion impairs the rollover motion of the 1st MTPJ and recent studies of patients with 1st MTPJ osteoarthritis show increased plantar forces on the hallux. Objectives. Our aim was to examine the plantar force variables under the hallux and the 1st, 2nd, and 3rd – 5th distal metatarsal head (MH) on patients operated with a proximal hemiarthroplasty (HemiCap) in the 1st MTPJ and compare to a control group of healthy patients. Secondary aims: To examine correlations between the force and the 1st MTPJ range of motion (ROM) and pain. Study Design & Methods. Seventy patients operated with HemiCap were invited. 41 were included, (10 men, 31 women), median operation date 2011(range 2007–2014), age 63(47–78), 37 unilateral and 4 bilateral. Dorsal ROM of the 1st MTPJ was measured by goniometer and by x-ray. Pain evaluated by visual analog scale (VAS 1–10) during daily activities (DA) and during testing (DT). Emed (Novel) Foot Pressure Mapping system was used to measure peak force (N) and force/time integral (N/s) under the hallux, 1st and 2nd and 3–5th metatarsal heads (MH). Statistics: Force variables between operated feet and control group were compared by independent two-sample t-test or Wilcoxon rank sum test. Force variables association to ROM and pain by linear regression models. Results. Median (range) for HemiCap/Control group: Peak force (N): Hallux: 12(1–26)/20(4–30), 1st MH: 17(8–41)/24(14–42), 2nd MH 24(15–37)/28(24–37), 3rd–5th MH: 27(18–36)/30(25–35). Force/time integral (N/s): Hallux: 1(1–4)/4(1–12), 1st MH: 5(2–18)/7(3–11), 2nd MH 8(4–13)/10(7–13), 3rd–5th MH: 9(6–15)/10(8–14). Significant difference between HemiCap patients and healthy controls in peak force and force/time integral was found under the hallux (p<0.01), 1st (p<0.05) and 2nd MH (p<0.05), and max force under the 3–5th MH (p<0.01). Dorsal ROM of the operated feet was 45 degrees (10–75) by goniometer and 41 degrees (16–70) by x-ray. An increase in dorsal ROM decreased the peak force and force/time integral under the hallux (p>0.05) but not under the MHs. Most patients reported no pain (VAS 1: 62% DA, 78% DT), only 2 patients reported VAS>3. No significant correlation between pain and force or force/time integral. Conclusions. A mid-term hemiarthroplasty do not restore the joint motion to normal. The loading patterns are in opposition to AO patients as as assfgjkdfgjkfdgjk the HemiCap patients show a significantly decreased peak force and force/time integral under the hallux compared to the control group and the larger the dorsiflexion achieved postoperatively the smaller the force/time integral becomes. It may reflect a patient reluctance to load the 1st ray and 2nd MH. The plantar forces are not linked to pain. Most report minimal pain, but the pain score is biased by missing numbers and exclusion of revisions

Tenodesis effect and digital cascade of the foot were never described in the current literature. However, understanding of these effects are important in the diagnoses and managements of foot flexor tendon rupture and lesser toe deformities. We aim to investigate the presence of these effects in the foot with intact and cut tendons. Ten fresh frozen cadaveric specimens were used in our study. 2. nd. , 3. rd. and 4. th. toe metatarsophalangeal joint (MTPJ) and proximal interphalangeal joint (PIPJ) range of motion (ROM) at ankle resting position were measured. Same measurements were repeated with maximum ankle plantarflexion and dorsiflexion. 4. th. toe Flexor Digitorum Longus (FDL) was then identified over plantar aspect of metatarsal shaft and cut transversely. 2. nd. , 3. rd. and 4. th. toe MTPJ and PIPJ ROM at ankle resting position, maximum plantarflexion and dorsiflexion were then measured. Mean 4. th. toe MTPJ and PIPJ ROM at ankle dorsiflexion were 13.5 ° of dorsiflexion and 25 ° of plantarflexion respectively, compared with values at ankle plantarflexion which were 35 ° and 25 ° respectively. After 4. th. toe FDL was cut, mean 4. th. toe MTPJ and PIPJ ROM at ankle dorsiflexion were 14 ° and 24 ° respectively and at ankle plantarflexion the values were 34.5 ° and 25 ° respectively. At ankle resting position before 4. th. FDL was cut, mean 4. th. toe MTPJ and PIPJ ROM were 22 ° and 31 ° respectively, compared with the values after 4. th. FDL was cut, ie 22.5 ° and 30.5 ° respectively. Tenodesis effect of the foot was shown in our study. However unlike in hand, this effect was only present in MTPJ and was still present following cut FDL. Similarly, digital cascade was still present following cut FDL. The maintenance of tenodesis effect and digital cascade following cut flexor tendon is likely contributed by various soft tissue restraints and intrinsic muscle actions. These findings are important in both the diagnosis and management of foot flexor tendon rupture and help us to better understand the biomechanics of lesser toe deformities and the managements of these deformities

Hammer toe involves metatarsophalangeal joint (MTPJ) hyperextension and proximal interphalangeal joint (PIPJ) flexion. Surgery commonly involves excision arthroplasty or fusion of the PIPJ with MTPJ soft tissue release if necessary. Previous series record that MTPJ release was carried out “as required” but not how often release is necessary. Myerson and Shereff's (1989) cadaver study found release of the extensors, MTPJ capsule and collateral ligaments necessary for full hammertoe correction. Hossain (2002) found the clinical results of this procedure were no better than simple PIPJ fusion. We release the MTPJ if hyperextension persists after PIPJ correction and release the components sequentially. We studied how often and how extensive a release was required, and how this corelated with pre-operative assessment. We reviewed the records of 164 patients who had hammer toe correction under one consultant surgeon. Patients with complex corrections were excluded. The severity of the pre-operative deformity was classified as type 1 (PIPJ and MTPJ correctable), 2 (PIPJ fixed, MTPJ correctable) or 3 (neither joint correctable). We recorded the extent of release required for each toe. Results. Of 334 type 2 toes in 146 patients, 178 (53.3%) required no MTPJ release, 11 (3.3%) extensor tenotomy only, 15 (4.5%) extensor tenotomy and MTPJ dorsal capsulotomy and 130 (38.9%) extensor tenotomy, capsulotomy and collateral ligament release. Of 31 type 3 toes in 18 patients, one (3.2%) needed no release, 2 (6.5%) tenotomy, one (3.2%) capsulotomy and 27 (87.1%) complete release. Discussion. Nearly 50% of toes needed MTP soft tissue release, partial in 8%. Pre-operative assessment was not very accurate in predicting the need for release. We have not yet correlated need for release with clinical outcome. Conclusion. MTP release is required in many hammertoe corrections. Assessment of toe position after incision of each structure may avoid the need for complete release

Background. Hallux rigidus is a common condition characterised by first metatarsophalangeal joint (MTPJ) degeneration, pain and limited range of motion (ROM). The gold standard surgical treatment is arthrodesis, providing good pain relief but sacrifices ROM. Recently the Cartiva synthetic cartilage implant (SCI) has been utilised as an interpositional arthroplasty, aiming to reduce pain whilst preserving range of motion. Current evidence for Cartiva SCI is largely based on a single cohort with mixed outcomes. We sought to evaluate the clinical outcomes of Cartiva SCI compared to arthrodesis undertaken in our centre. Methods. Retrospective review of patients undergoing Cartiva SCI or arthrodesis for treating hallux rigidus was conducted. Preoperative arthritis was radiographically graded using the Vanore classification. Patient reported outcomes (PROMs) were assessed using EuroQol 5-dimension score (EQ-5D-5L) and Manchester-Oxford Foot Questionnaire (MOXFQ). Results. Between 2017 and 2020 there were 33 cases (17 Cartiva, 16 arthrodesis, mean age 59.0±9.9 years) with a mean follow up of 2.3 years. For the first MTPJ arthrodesis cohort, the MOXFQ domain scores were: Index 3.9±5.8, Walking/Standing 5.1±7.6, Pain 3.2±5.0, and Social Interaction 2.6±4.0. EQ-5D-5L Index score was 0.828±0.270 and the EQ-VAS was 72.5±23.3. For the Cartiva cohort, the MOXFQ domain scores were: Index 7.7±6.0, Walking/Standing 8.9±7.9, Pain 7.1±5.0, and Social Interaction 6.4±5.4. EQ-5D-5L Index score was 0.631±0.234 and the EQ-VAS was 74.8±20.8. There was no statistically significant difference between any MOXFQ domain or EQ-5D-5L scores. However, a negative trend in MOXFQ domains was identified for the Cartiva group, as well as a reoperation rate of 23.5%. Conclusions. The Cartiva SCI demonstrated no advantage over arthrodesis in PROMs, despite the presumed benefit of preserved ROM. A significant reoperation rate was also observed. Surgeons should be cautious in the use of this novel implant

Arthrodesis of the first metatarsophalangeal joint (MTPJ) has been reported as gold standard for the treatment of advanced hallux rigidus and is a well-documented procedure. However, many patients demand a mobile MTPJ and therefore joint sparing procedures like MTPJ-arthroplasty have gained popularity. The aim of the present study was to present first mid-term results after hemiarthroplasty to treat advanced osteoarthritis of the first MTPJ. Between April 2006 and October 2013, a total of 81 hemiprostheses (AnaToemic®, Arthrex) in 71 consecutive patients (44 females, 27 male, 10 bilateral; mean age, 58 [range, 45–82]) were implanted at the St. Vincent Hospital Vienna (Austria). The indication for surgery was persistent MTPJ pain after failed conservative treatment combined with radiologic evidence of osteoarthritis (advanced hallux rigidus grade II-IV). Patients were clinically examined using the American Orthopaedic Foot and Ankle Society (AOFAS) score before surgery and at the final follow-up visit. Patient's satisfaction with the treatment was recorded. Radiological results were evaluated using standard x-rays and revision surgeries were documented. The mean preoperative AOFAS Scores significantly increased from 51 to 88 points after an average follow-up duration of 5 years (p<0.001). Most patients (76%) were either very satisfied or satisfied with the procedure. Radiological assessment showed some kind of radiolucencies on the base plate, whereas the stem of the prosthesis was well integrated in most of the cases; however clinical outcome was not affected by minor radiolucent lines on the base plate. In the majority of patients the implant was in situ at last follow-up. If revision surgery, due postoperative pain or implant loosening, was required; it occurred within 12 to 36 months. According to our promising mid-term results with a MTPJ-hemiprostheses, we conclude that MTPJ-arthroplasty is an effective alternative treatment modality for anatomical reconstruction of the first MTPJ with the benefit to reduce pain and maintain mobility

A dorsal incision is made over the metatarso-phalangeal joint (MTPJ) extending 2cm proximally and distally from the joint line. A routine cheilectomy of the MTPJ is performed. The Extensor digitorum longus (EDL) tendon is identified and divided through a separate incision 5 cm proximal to the MTPJ at the mid-foot level. A 3/0 vicryl stay suture is placed in the divided tendon. The tendon is retrieved from the distal wound and mobilised along with the extensor expansion and the dorsal capsule to expose the proximal half of the proximal phalanx. The transverse fibres of the extensor expansion and the MTPJ capsule are divided medially and laterally with preservation of the collateral ligaments. Extensor digitorum brevis is identified and protected. A groove is created on the dorsum of the proximal phalanx at the centre of the articular surface to stabilise the EDL tendon in its final position. A 3.2mm tunnel is then created at a 45 degree angle through the metatarsal neck beginning dorsally 2.5cm from the metatarsal articular surface and exiting just proximal to the plantar plate. The mobilised EDL tendon, expansion and capsule are then passed down through the MTPJ via a perforation in the plantar plate. The EDL tendon is then passed through the tunnel from plantar to dorsal where it is sutured to the periosteum of the metatarsal using a 3/0 vicryl suture. Hence the EDL tendon, expansion and dorsal capsule form an interposition arthroplasty. Eleven patients with an average age of 37 years underwent the above procedure for Freiberg’s Disease or osteoarthritis of the second or third MTPJ. There were no intra-operative complications and at an average 31 month follow up 70% were pain free. We recommend the Cobb II procedure as a primary management option for MTPJ Freiberg’s Disease/osteoarthritis

Introduction. The aim of this study is to better understand the anatomy of the forefoot to minimise surgical complications following minimally invasive forefoot surgery. Methods. The study examines the plantar anatomy of the lesser toes in ten cadaver feet. The tendons, nerves and bony anatomy are recorded. Results. The anatomy of the flexor tendons reveals the short flexor tendon bifurcates to allow the long flexor tendon to pass through it reliably at the level of the metatarsophalangeal joint (MTPJ) in the lesser rays. The division of the intermetatarsal nerves to digital nerves relative to the MTPJ is more variable. This nerve division is more consistently related to the skin of the web between the toes. In the first webspace the division is on average 3cm proximal to the skin at the deepest part of the cleft. In the second, third and fourth webspaces this distance is reduced to 1cm. The level of the deepest part of the webspace to the MTPJ is also variable. Discussion. Surgical release of the flexor tendons is recommended just proximal to the MTPJ for releasing both tendons and distal to the proximal interphalangeal joint for the long flexor tendon. The webspace skin and MTPJ's are easily identifiable landmarks clinically and radiologically. Awareness of the intermetatarsal nerve division will help to reduce nerve injuries with minimally invasive surgery to the plantar forefoot

The August 2012 Foot & Ankle Roundup. 360. looks at: calcaneocuboid distraction arthrodesis with allograft for acquired flatfoot; direct repair of the plantar plate; thromboembolism after fixation of the fractured ankle; weight loss after ankle surgery; Haglund’s syndrome and three-portal endoscopic surgery; Keller’s procedure; arthroscopy of the first MTPJ; and Doppler spectra in Charcot arthropathy

The incidence of first metatarsophalangeal joint (MTPJ) stiffness following bunion surgery varies in the literature from 2% to 60%. The causes include pre-existing degenerative joint disease, infection, chronic regional pain syndrome (Type 1), joint incongruence and avascular necrosis. The aim of this study was to establish whether closure of the capsule influences the range of motion in the first MTPJ. We performed a cadaveric study using a ‘Y’ shaped medial capsulotomy as our model. A mid-medial approach was performed on ten cadaveric feet, exposing the medial capsule of the 1st MTPJ. The range of motion of the 1st MTPJ was recorded, and a ‘Y’ shaped capsulotomy performed. The capsule was then closed in neutral, full plantar flexion, and full dorsi flexion and the range of motion recorded. When the capsule was closed with the first MTPJ at the limit of plantar flexion there was a mean loss of 13.7° of dorsi-flexion (range 12°–15°, p< 0.01) compared with the pre-capsulotomy range of motion. When the capsule was closed in dorsi-flexion there was a mean loss of 9.3° of plantar flexion (range 0°–20°, p< 0.05). There was no change in range of motion when the capsule was closed in neutral. Capsular closure can influence first MPTJ motion. Care should therefore be taken during capsular repair. Closure in extremes of extension or flexion, as advocated in some techniques such as the Mitchell osteotomy, should be avoided

Arthrodesis of the first metatarsophalangeal joint (MTPJ) is the gold standard treatment of a wide range of pathologies involving the 1st MTPJ. Numerous methods of internal fixation and bone end preparation have been reported to perform this procedure, however there is no universal technique. Therefore in an effort to bring together the best features of the different surgical techniques, a low profile contoured titanium plate (Hallu-S plate), with a compression screw, with a ball and socket bone end preparation were designed. A prospective study was carried out to determine the efficacy of using the Hallu-S plate for 1st MTPJ arthrodesis. 1st MTPJ arthrodesis, using the Hallu-S plate, was carried out in 11 consecutive patients. The procedure was performed in isolation and with other forefoot procedures. Cast immobilization was not used in patients with an isolated 1st MTPJ arthrodesis and the patients were allowed to mobilize (heel walking – full weight bearing) between 2 and 6 weeks postoperatively. The changes in the level of pain and activities of daily living using the AOFAS Hallux score, pre-operatively and at the last assessment, and the time to bone union were assessed. The mean follow-up time was 10 months (STD 6 months) and there was statistically significant increase in the AOFAS Hallux score. All radiographs at 6 weeks showed bone union and an appropriate degree of dorsiflexion in relation to 1st metatarsal (20–25). The combination of the Hallu-S plate and a ball and socket preparation has both operative and biomechanical advantages over previously described techniques. This combination ensures the biomechanics of the 1st ray are maintained and a better functional result is achieved

The first MTP Joint (MTPJ) is critical in normal gait. MTPJ replacements treat the articular surface as a hemisphere, as it appears radiographically. In reality the articular surface has two grooves to accommodate sesamoids and facilitate a better range of motion. We compare a standard hemispherical and a modified grooved implant. Six cadaver feet were implanted with Toefit 1st MTPJ replacements and sequentially four different metatarsal head implants. Two of the metatarsal heads had grooves. The intact joints were used as a baseline for comparison, with their measurements taken before implantation. Each construct had a standard dorsiflexion force applied (50N). Flexion angle was measured on lateral radiographs. Contact pressure and area were measured with a pressure transducer (Tekscan I-Scan 6900 electronic pressure sensor). The anatomical (grooved) implants showed higher flexion angles and lower contact pressures in each case although there were too few trials to reach statistical significance. Results suggest a tendency towards better flexion and contact pressure characteristics in a more anatomical device. This may lead to better clinical outcomes for 1st MTPJ replacements