In most cases the etiology of Hallux rigidus is unknown. The purpose of this presentation is to discuss the classification of hallux rigidus, as well as the treatment options for every stage. Treatment suggestions should be individualised depending not only on the grade of the hallux rigidus, but also the patient's expectations. These include expectations regarding footwear, recreational activities and the potential of further surgeries depending upon the initial choice of treatment. Emphasis will be placed on joint preserving options, including adding a Moberg osteotomy to proximal halangs to increase perceived dorsiflexion of the great toe

Purpose of study:. Congenital hallux varus is a rare condition presenting with medial deviation of the big toe. It consists of 2 variants: classical congenital hallux varus caused by an abnormal metatarsal-phalangeal articulation, and a more recently described variant due to a “bracket physis” of the first metatarsal. Our aim was to perform an audit of the spectrum of presentation of congenital hallux varus with its management and complications in our unit over a five year period. Description of methods:. A retrospective review of congenital hallux varus treated by a single surgeon was performed. Clinical notes, photographs and x-rays were reviewed. Two surgical methods of treatment were used as directed by clinical and radiological findings. Summary of results:. Four patients with congenital hallux varus were identified. Three had bilateral involvement, i.e. seven feet were treated. The ages of the patients ranged from 1 to 9 years, with 2 boys and 2 girls receiving treatment. In two patients (4 feet) the deformity was associated with pre-axial polydactyly. One patient had associated hand deformities. Only one of our four patients had a “bracket physis” and was treated with a metatarsal osteotomy. The other three patients (6 feet) were treated by soft tissue realignment using the Farmer procedure. One patient who had bilateral Farmer procedures subsequently developed a bunion over the 1st metatarso-phalangeal joint of one foot due to uncovering of the metatarsal head. No complications or recurrences were recorded in the other three patients on follow up visits. Conclusion:. Careful clinical and X-ray analysis is important to determine the type of congenital hallux varus and which method of surgical treatment is appropriate. Long term follow up is required to identify subsequent deformities

Introduction:. Hallux surgery is the most commonly performed elective surgery in the foot and ankle. As with all surgery, there are many potential complications quoted in the literature. Venous thromboembolism (deep vein thrombosis and pulmonary embolism) incidence and prophylaxis, however, is not adequately addressed and remains controversial. Material and Method:. This prospective study includes one hundred patients who underwent hallux surgery. Risk factors implicated to increase the risk of developing venous thromboembolic disease as well as anaesthetic time, thigh tourniquet time and regional anaesthetic blocks were documented. Compressive ultrasonography was performed in all the patients postoperatively to assess for deep vein thrombosis. Results:. There was one incident of calf deep vein thrombosis (DVT). No patient developed a pulmonary embolus. The one patient who developed a DVT was not at any higher risk than the average patient in the study. Conclusion:. As a result of the low incidence of venous thromboembolic disease in this study, the authors do not recommend the routine use of chemical venous thrombo-prophylaxis in patients undergoing hallux surgery. The decision to give postoperative anticoagulation remains the surgeon's responsibility. The duration of prophylaxis will depend on when the patient is fully mobile

Short scarf osteotomy (SSO) retains the versatility of standard scarf in treating moderate and severe hallux valgus deformity with the added benefit of less invasiveness translated into less soft-tissue stripping, reduced exposure, less metalwork, less operative time and reduced cost. We present our medium-term clinical, radiographic and patient satisfaction results. All patients who underwent SSO between January 2015 and December 2017 were eligible (98). Exclusion criteria were: follow up less than a year, additional 1st ray procedures, inflammatory arthropathy, infection, peripheral vascular disease and hallux rigidus. Eighty-four patients (94 feet) were included: 80 females / 4 males with average age of 51-year-old (24–81). Minimum follow up was 12 months (12–28). Weight-bearing x-rays and AOFAS score were compared pre- and postoperatively. Non-parametric Mann-Whitney U test assessed statistical significance of our results. Hallux valgus angle (HVA) improved from preoperative mean of 30.8° (17.4°–46.8°) to 12° (4°–30°) postoperatively (p=0.0001). Intermetatarsal angle (IMA) improved from preoperative mean of 15.1° (10.3°–21.1°) to 7.1° (4°–15.1°) postoperatively (p=0.0001). Average sesamoid coverage according to Reynold's tibial sesamoid position improved from average grade 2.18 (1–3) to 0.57 (0–2) (p=0.0001). Average AOFAS score improved from 51.26 (32–88) to 91.1 (72–100) (p=0.0001). Ninety percent of patients were satisfied and 83% wound recommend the surgery. No troughing phenomenon or fractures. Four overcorrections were found 3 of which did not require surgery. One recurrence at 18 months was treated with standard scarf. We believe that this technique offers a safer, quicker and equally versatile way of dealing with Hallux Valgus

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

Hallux valgus is a common condition often leading to significant symptoms. However, its correction has recently been suggested, to be a procedure of limited clinical value. Scarf osteotomy is one of the most commonly performed operations for hallux valgus correction. Although technically demanding, it is powerful in its capacity to correct the hallux valgus deformity and sufficiently robust with internal fixation to allow early weight bearing. We prospectively collected data for consecutive scarf osteotomies between 2008 and 2011. Preoperative and 6 week postoperative assessment was made using radiographic measurements HVA (hallux-valgus angle) and IMA (inter metatarsal angle). We evaluated 130 scarf osteotomies. The mean HVA improved from 29.5 pre-operatively to 12.6 post correction. The mean IMA improved from 12.4 pre-operatively to 8.1 post correction. The AOFAS hallux scores improved from an average of 55 pre op to 79 post operation. The results suggest that hallux valgus correction does have clinical value and that scarf osteotomy is a reproducible procedure, with a generally good to excellent results in the short term

Introduction. Minimally Invasive foot surgery remains controversial. Potential benefits include a reduced incidence of wound complications, faster return to employment and normal footwear. There are no studies published regarding the results of minimally invasive dorsal cheilectomy. Patients and Methods. Thirty eight patients with painful grade I hallux rigidus underwent dorsal cheilectomy between April 2006 and June 2010. Minimally invasive cheilectomy (MIC) was introduced in August 2009. AOFAS scores, satisfaction, return to normal shoes and employment were assessed. Results. Twenty two patients had open cheilectomy (OC) whilst 16 had MIC. Mean follow-up was 6 months for the MIC group and 35 months for the OC group. Mean AOFAS score was 75/100 (SD 17) in the MIC group and 70/100 (SD 18). Patients rated their satisfaction as 9.1/10 for MIC and 8.6/10 for OC. There was no significant difference in time to return to normal shoes (P = 0.32) or employment (P = 0.07). Two patients (one MIS, one OC) had a superficial wound infection which resolved with oral antibiotics. One patient had a first metatarsophalangeal joint fusion in the MIS group. Two patients in the OC group went on to have a first metatarsophalangeal joint fusion and one underwent joint resurfacing. Discussion. These results suggest MIC has comparable early results to OC. Larger studies are required to further establish the benefits of MIC. Conclusion. Minimally invasive dorsal cheilectomy seems to offer a safe alternative to open cheilectomy with promising early results. Patient satisfaction with this procedure is very high

Hallux valgus surgery can result in moderate to severe post-operative pain requiring the use of narcotic medication. The percutaneous distal metatarsal osteotomy is a minimally invasive approach which offers many advantages including minimal scarring, immediate weight bearing and decreased post-operative pain. The goal of this study is to determine whether the use of narcotics can be eliminated using an approach combining multimodal analgesia, ankle block anesthesia and a minimally invasive surgical approach.

Following ethics board approval, a total of 160 ambulatory patients between the ages of 18-70 with BMI ≤ 40 undergoing percutaneous hallux valgus surgery are to be recruited and randomized into Narcotic-free (NF) or Standard (S) groups. To date, 72 patients have been recruited (38 NF and 34 S). The NF group received acetaminophen, naproxen, pregabalin 75mg and 100mg Ralivia (tramadol extended release) before surgery and acetaminophen, naproxen, pregabalin 150mg one dose and Ralivia 100mg BID for five days, as well as a rescue narcotic (hydromorphone, 1mg pills) after surgery. The S group received acetaminophen and naproxen prior to surgery and acetaminophen, naproxen and hydromorphone (1mg pills) post-operatively, our current standard. Visual analog scales (VAS) were used to assess pain and narcotic consumption was recorded at 6, 12, 24, 36, 48, 72 hours and seven days post-operatively. Patients wore a smart watch to record the number of daily steps and sleep hours. A two-sided t-test was used to compare the VAS scores and narcotic consumption.

During the first post-operative week, the NF group consumed in total an average of 6.5 pills while the S group consumed in total an average of 16 pills and this difference was statistically significant (p-value=0.001). Importantly, 19 patients (50%) in the NF group and four patients (12%) in the S group did not consume any narcotics post-operatively.

For the VAS scores at 24, 48, 72 hours and seven days the NF group's average scores were 2.17, 3.17, 2.92, 2.06 respectively and the S group's average scores were 3.97, 4.2, 3.23, 1.97. There was a statistically significant difference between the groups at 24 and 48hours (the NF group scored lower on the VAS) with a p-value of 0.0008 and 0.04 respectively, but this difference is not considered clinically significant as the minimal clinically important difference reported in the literature is a two-point differential. The NF group walked an average of 1985.75 steps/day and slept an average of 8h01 minute/night, while the S group walked an average of 1898.26 steps/day and slept an average of 8h26 minutes/night in the first post-operative week. Hallux valgus remains a common orthopedic foot problem for which surgical treatment results in moderate to severe post-operative pain. This study demonstrates that with the use of multimodal analgesia, ultrasound guided ankle blocks and a percutaneous surgical technique, narcotic requirements decreased post-operatively. The use of long-acting tramadol further decreased the need for narcotic consumption. Despite decreased use of narcotics, this combined novel approach to hallux valgus surgery allows for early mobilization and excellent pain control.

First Metatarsophalangeal joint fusion has been successfully used to treat Hallux rigidus. We have attempted to evaluate commonly used methods of fixation and joint preparation. To the best of our knowledge, this is the single largest comparative study on first MTPJ fusion. We aimed to evaluate the radiological union and revision rates. We included 409 consecutive MTPJ fusions performed in 385 patients. We collected demographic, comorbidities and complication data. We evaluated the radiographs for the status of the union. Logistic regression was used to calculate the Odds ratio (OR) of non-union for the collected variables. Our union rate was 91.4% (34/409). 29.4% of our non-unions were symptomatic (10/34). Hallux valgus showed a statistically significant relation to non-union (Odds ratio 9.33, p-value 0.017). Other potential contributing factors like sex (OR1.9, p-value 0.44), diabetes (OR 0, p-value 0.99), steroid use (OR 2.07, p-value 0.44), inflammatory arthritis (OR 0, p-value 0.99) and smoking (OR 2.69, p-value 0.34) did not attain statistical significance. Further, the methods of fixation like solid screws (OR 0, p-value 0.99), plate (OR 3.6, p-value 0.187) or cannulated screws (OR 0.09, p-value 0.06) showed no correlation with non-union. We compared two techniques of joint preparation and found no significant difference in union rates (Chi-Square 1.0426, p-value 0.30). Our crude cost comparison showed the average saving to the trust per year could be 33,442.50£ by choosing screws over plate. Only Hallux Valgus had a statistically significant relation to non-union. Solid screw could be economically the most viable option and a valid alternative

Introduction. Despite the multiple patho-aetiological basis of Hallux valgus (HV), corrective osteotomy is a common and globally performed orthopaedic procedure. Over-correction of the inter-metatarsal angle (IMA), however, is not without consequence. Through increased joint pressures, over-correction may predispose to joint degeneration. Hypothesizing that over-correction leads to an increase in intra-articular joint pressures, we constructed a mechanical simulation of the 1. st. metatarsal-phalangeal joint. Methods. The vector forces of Flexor Hallucis Longus, Extensor Hallucis Longus, Extensor Hallucis Brevis and Adductor Hallucis, acting upon the 1. st. proximal phalanx were simulated with tensioned weighted rope. A Foley catheter balloon inflated to 1.5ml, simulated intra-articular distractive vector forces. The joint was freely mobile. At 5° IMA intervals from 10° valgus to 15° varus, intrarticular pressures were recorded using a contact pressure (Graseby™, Hertfordshire, UK) transducer attached to a calibrated manometer (Digitech Instruments™, Ulhasnagar, India). At each angle, measurements were repeated five times with removal and recalibration of the pressure monitor after each measurement. Results. A decline and subsequent increase in mean pressure was observed at each 5° interval from 10°valgus to neutral and then to 15° varus (mean±s.d.; 48.02±5.67, 24.72±1.01, 12.34±0.84, 18.96±2.46, 32.88±5.06, 42.92±4.99 milibar for 10°, 5° valgus, neutral, 5°, 10°and 15° varus IMA). One-way analysis of variance with post-hoc Tukey multiple comparison test revealed a significant increase in pressure from neutral and 5° valgus to 10° and 15° varus (p< 0.05). [First Metatarsal Phalangreal joint pressures]. Conclusion. This is the first description demonstrating increases in intrarticular pressures as the IMA tended from 5° to 15° varus, replicating inatrogenic Hallux Varus iatrogenically produced through osteotomy and over-correction of the IMA. Over-correction and increased intrarticular joint pressure may have an aetiological basis to post-operative 1. st. MTPJ degeneration. Over-correction is not a benign entity requiring consideration in Hallux Valgus corrective osteotomy

Proximal Release of Gastrocnemius (PROG) is a procedure which can be performed to treat various disorders of the foot and ankle. Gastrocnemius contracture/tightening is a condition which can lead to many chronic debilitating foot conditions like Metatarsalgia, Hallux Valgus, Plantar Fascitis, Diabetic foot ulcers etc, which in turn can significantly affect patient's quality of life. In this study we present eight cases who presented with forefoot pain, were treated with PROG and showed a complete resolution of their condition. The test used to determine Gastrocnemius contracture is the “SILFVERSKIOLD TEST”. It measures the dorsiflexion (DF) of the foot at the ankle joint (AJ) with knee extended & flexed to 90 degrees. The test is considered positive when DF at the AJ is greater with knee flexed than extended. We studied eight patients who presented to the orthopaedic outpatients between 2005 and 2010 with diverse foot conditions and having relative equinism. Six out of eight patients suffered from forefoot pain, out of which three had associated diabetic neuropathy and one out of these three had a diabetic foot ulcer. One was in association with arthritis of Talonavicular & Transmetatarsal joint, another had callosity under the head of second metatarsal. One patient had claw toes with associated Rheumatoid Arthritis. One of our patients presented with spasticity in his left calf, severe Hallux Valgus & dislocated MTPJ. He had an unsuccessful Strayer procedure on the same leg in the past. The final case had Achilles tendonitis & spurs. A finding common to all of them pre operatively was a positive Silfverskiold test, all having ZERO degree DF at the AJ with knee extended. Surgical release of the aponeurotic head of gastrocnemius was performed in prone position through a transverse incision. A cam walker was used for two weeks in those patients who were permitted to weight-bear, else a plaster for two weeks. No surgical complications occurred. Success was measured both in returning the ability to dorsiflex and resolution of related condition. DF in extension improved from an average of zero to 16(sixteen) degrees. Seven out of eight patients(including the patient with planter ulcer)had resolution of associated condition. One failure was a patient who continued to experience neuropathic pain. None of the patients complained of any weakness as a result of release. PROG is a straightforward procedure and should be considered in patients where gastrocnemius tightening is likely to be the contributing factor. This seems to improve the success of related procedures

There are many types of arthroplasties for the 1st MTPJ, but still the treatment of advance Hallux rigidus remains controversial. In this study we are reporting the outcome of the North Star hemicap at 6 months. A series of patients under the care of a single surgeon were followed using the Manchester - Oxford Foot Questionnaire (MOXFQ) at 6months post operation, and a satisfaction question was asked. The operations were between August 2011 and August 2013. A total of forty five arthroplasties were implanted in 44 patients. Thirty four of them were female and 9 were male. The average age was 56 years (range 37–77 years). Twenty six out of them (59%) needed an MUA + a local anaesthetic and steroid injection of the prosthetic joint at 2 to 14 months (average 6 months) post implantation. In these patients the MOXFQ was filled at 6months post the MUA and injection. Four of them were left out of the study because they were less than 6months post MUA. One patient had his implant removed and changed to fusion at his request at 14 months post implantation. Forty one patients were satisfied and would recommend the operation, 2 were disappointed with the degree of movement but would still recommend the operation and one had it revised to fusion. The average MOXFQ was 12/64. In conclusion, high percentage of patients needed a second operation, but the scores are reasonably low and almost all patients would recommend it. Further follow up of these patients is needed for at least 5years but the early results are showing it to be a good alternative for fusion

Purpose:. To describe a plating technique for the Lapidus procedure as an alternative to the traditional screw fixation technique. To look at the complications experienced during the Lapidus procedure and to find possible solutions to prevent these complications. Methods:. A retrospective study of 34 Lapidus procedures in 26 patients (8 bilateral) between 2006 and 2009 was performed. All were done with a plating technique and a primary bone graft. The indications were:. metatarsus primus varus. hypermobility. degenerative TMT joint. Results:. The average intermetatarsal angle pre-operatively was 17.1° and this was reduced to 6,4° post – operatively. The complications experienced were:. post –operative metal removal = 6. transfer metatarsalgia = 1. hallux varus = 1. screw breakage = 1. delayed union = 1. non-union = 1. Conclusion:. The plating technique for the Lapidus procedure gives stable fixation and the outcome compares well with other methods of fixation

Aim:. To review the short to medium term radiological, clinical and functional outcomes of reconstructive surgery for severe forefoot deformities in patients with Rheumatoid arthritis. Methods:. We conducted a review of prospectively collected data of patients with Rheumatoid arthritis who received reconstructive surgery for forefoot deformities. Patients requiring metatarso-phalangeal joint arthrodesis and excision of the lesser metatarsals for hallux valgus, dislocation of the lesser metatarso-phalangeal joints and intractable plantar keratosis were included. The patients were followed up at 2 weeks, 6 weeks, 3 months and 6 months. X-Rays were performed preoperatively, postoperatively, at 6 weeks, 3 months and 6 months follow-up. Patients completed a SF36, and AOFAS (American Orthopaedic Foot and ankle Score) forefoot score preoperatively and at 6 months postoperatively. Results:. Ten feet in eight patients were included in the study. Follow-up was for a minimum of 6 months. All patients were female, with an average age of 58 years (34–69 years). Radiologically there was an average correction in the hallux valgus angle from 48 degrees to 15 degrees. The inter-metatarsal angle improved from 14 to 9 degrees. Objective scores were significantly improved. The mean SF36 score pre-operatively was 36 (24–54) and 67 (54–82) post operatively (P < 0.05). The AOFAS score improved from a mean of 32 (28–50) pre operatively to 74 (64–78) post-operatively (p < 0.05). One patient required re-operation for further metatarsal shortening due to ongoing pain and two patients required oral antibiotics for minor superficial wound infections. All hallux metatarsophalangeal joint arthrodesis procedures united in a mean time of 3.5 months. Conclusion:. Forefoot reconstruction in these very symptomatic, disabled patients resulted in significant deformity correction and improvement in function and pain. The complication rate was low. Adequate resection of the lesser metatarsals is necessary to avoid ongoing pain from the phalanx articulating with the metatarsal

Background. There are reports of good early results in small numbers of patients implanted with the ‘Moje’ ceramic prosthesis. Published evidence thus far involves only small groups of patients with short-term follow-up. The purpose of this prospective study was to evaluate the emerging mid-term clinical and radiological results from our centre. Methods. We describe our single-surgeon experience of 63 components in 48 patients at a mean follow-up of 44 months. Patient satisfaction was assessed by questionnaire and radiographic assessment was performed immediately post-operatively and at the maximum follow-up. Results. Mean American Orthopaedic Foot and Ankle Society (AOFAS) Hallux score increased from 56 to 72 (p< 0.01) and mean satisfaction score was 7.6 (scale 1-10). 67% reported minimal or no pain. Five implants have been removed (8%), four because of pain associated with implant loosening and subsidence, and one because of deep infection. 57% of metatarsal and 56% of phalangeal components had subsided and we found radiographic evidence of loosening in 58% of x-rays analysed at the maximum follow-up. Presence of prosthesis subsidence was associated with greater margin of uncovered bone under the prosthesis (P=0.05 for metatarsal, P=0.03 for proximal phalanx component) and longer time to follow-up (P< 0.001). Conclusion. In spite of the good clinical outcome at the mid-term stage with 91% implant survival, given the widespread loosening and subsidence encountered in our study, the long-term outcome following this procedure is uncertain

Introduction. In cases of unilateral clubfoot, the leg and foot is visually smaller than the opposite, uninvolved side. Parents want to know how much smaller the leg and foot will be. The purpose of this study was to answer this question and compare the results of children treated with a posterior medial release (PMR) with those treated with the Ponseti method (PM). Methods. This is a prospective, longitudinal study of calf circumference and foot length. We measured the calf circumference with a tape measure at the visually maximum girth of the uninvolved side and at the symmetrical position of the involved side. We measured each foot length from the tip of the hallux to the end of the heel. We recorded the measurements at each follow-up visit in a database and analysed the data using linear regression analysis. Results. We followed 93 children (65 PMR, 28 PM) for a mean of 68 months (SD 55, range 6-252) The ratio men/women was 53/40. Mean percent calf size difference was 9.83% (95%CL 8.74-10.92%). Mean percent foot size difference was 8.70% (95%CL 7.54-9.87%). From the numbers available, no differences between the two procedures are evident. Conclusion. Children with a unilateral clubfoot have c10% smaller calf circumference and foot length as compared to the uninvolved side. We found no differences between children treated with PMR or PM, implying the smaller size is intrinsic to the condition and not due to type of treatment

Introduction. The anatomy of the first metatarsophalangeal (MTP) joint and, in particular, the metatarsosesamoid articulation remains poorly understood. The movements of the sesamoids in relation to the metatarsal plays a key role in the function of the first MTP joint. Although the disorders affecting the sesamoids are described well, the movements of the metatarsosesamoid joints and the pathomechanics of these joints have not been described. We have performed a cadaver study detailing and quantifying the three dimensional movements occurring at these joints. Methods. Fresh frozen cadaveric specimens without evidence of forefoot deformity were dissected to assess the articulating surfaces throughout a normal range of motion. The dissections were digitally reconstructed in positions ranging from 10 degrees of dorsiflexion to 60 degrees of plantarflexion using a Micro Scribe, enabling quantitative analyses in a virtual 3D environment. Results. The sesamoids demonstrated excursion both in the sagittal and coronal plane. The tibial sesamoid had a mean saggital excursion of 14.2 mm; the mean excursion of the fibular sesamoid was 8.7 mm. The mean coronal excursion of the tibial sesamoid was 2.8 mm while that of the fibular sesamoid was 3.2 mm. We also describe the mean saggital and coronal excursion of the sesamoids during smaller, incremental motions of the MTP joint. Conclusion. There appears to be differential tracking of the hallucal sesamoids. The tibial sesamoid has comparatively increased longitudinal excursion whilst the fibular sesamoid has comparatively greater lateral excursion. Clinical relevance. The greater excursion of the tibial sesamoid could explain the higher incidence of pathology in this bone. The differential excursion of the sesamoids is also a factor that should be considered in the design and mechanics of an effective hallux MTP joint arthroplasty

Open cheilectomy is an established surgical treatment for hallux rigidus. Cheilectomy is now being performed using minimally invasive(MIS) techniques. In this prospective study we report the outcome of minimally invasive cheilectomy comparing the results with a matched group who had cheilectomy using standard open procedure. Prospective study of 47 patients. 22 patients had MIS cheilectomy between March 2009 and September 2010. We compared the outcome with a matched group (25 patients) who had open cheilectomy. Functional outcome was assessed using the Manchester Oxford Foot and ankle questionnaire (MOXFQ). The MOXFQ is a validated 16-item, patient-generated questionnaire designed to be self-completed and used as an outcome measure for foot surgery. It comprises three domains foot pain, walking and standing problems and social interaction. Total score ranges from 0 (best score) to 64 (worst score). Patients completed preoperative and postoperative questionnaires. Patients’ satisfaction and complications were recorded. In the MIS group, the median follow up was 11 months (4–23. The median preoperative MOXFQ score was 34/64(23) and the median postoperative score was 19/64 (p value <0.02) In the open group the median follow up was 17 months (9–27). The median preoperative MOXFQ score was 35/64 and the median postoperative score was 7.5/64 and this difference was statistically significant (<0.0001). There were three failures in the open group (Fusion) compared to none in the MIS. MIS cheilectomy is an effective alternative procedure with satisfactory functional outcome and high patient satisfaction. Results are comparable to the standard open cheilectomy with a lower apparent failure rate. The results of our randomised controlled trial comparing MIS cheilectomy to open cheilectomy are awaited

Introduction. The operative management for Distal Tibialis Anterior Tendinopathy (DTAT) without rupture has not previously been described. We present 15 cases. Method. of 39 patients diagnosed clinically and radiographically with DTAT, we reviewed the 13 patients who underwent surgery for failure of non-operative management. Assessment included pre and post-operative AOFAS midfoot scoring, clinical examination and post-operative VAS pain scoring. Results. Twelve women (13 feet) and one man (two feet) underwent surgery. Mean age at surgery was 59 years (42 to 76 years). The mean duration of symptoms prior to surgery was one year (5 to 25 months). The mean pre-operative AOFAS score was 50 (23 to 75). Pre-operative MRI showed tendinosis in six tendons and tendinosis with longitudinal split tears in nine tendons. Five of the 14 cases showed some associated degenerative changes of the midfoot. Six tendons were simply debrided and the insertion reinforced with a suture anchor. Nine tendons were augmented with an Extensor Hallucis Longus (EHL) transfer into the medial cuneiform. The mean improvement in AOFAS score was 35 (4 to 57), with mean post-operative pain VAS of 1 (0 to 6.7) at a mean follow-up of 24 months (three to 65). Two patients underwent concomitant procedures on the same foot. Four of the nine treated with EHL transfer have some symptomatic hallux interphalangeal joint extensor lag. In seven cases the patient was completely satisfied. Five were satisfied with minor reservations. Of the three that were dissatisfied, two underwent subsequent surgery improving their symptoms. The third, though pain-free, was troubled by her toe catching when walking barefoot. No patients regret having had the surgery. Conclusion. Debridement and repair of DTAT, with EHL augmentation for greater than 50% tendon involvement, provides a high level of patient satisfaction if non-operative management fails

Introduction. Arthrodesis of the 1st metatarso-phalangeal joint (MTPJ) is a common procedure in forefoot surgery for hallux rigidus and severe hallux valgus. Debate persists on two issues - the best preparation method for the articular surfaces, and the optimal technique for operative stabilisation of the joint. Methods. We performed 1. st. MTPJ arthrodesis in 100 patients randomized into two equal groups. In the first group, the articular surfaces were prepared using cup-and-cone reamers, whilst in the second group, ‘flat cut’ osteotomies were performed with an oscillating saw. In all other respects, their treatment was identical. Fixation was secured using a plantar double compression Fixos™ screw and dorsal Anchorage™ plate. Full weight-bearing was allowed on the first post-operative day. Patients completed self-administered satisfaction questionnaires, including an AOFAS and SF-36 score pre-operatively and at two and six months post-operatively. Clinical examination and radiographs were compared at zero, two and six months. Statistical analysis was performed using Instat. Results. Radiographic union of the 1. st. MTPJ was documented in 45/50 patients in the reamer group and 42/50 in the ‘flat-cut’ group at two months and in all patients at six months. The AOFAS score improved from a mean of 46 +/− 15 pre-operatively to 72 +/−8 (out of 90) at two months and 83 +/− 4 (out of 90) at six months. SF-36 subscales for bodily pain and for physical function increased from 42.4 +/− 16.1 and 37.3 +/− 12.8 respectively pre-operatively to 82.2 +/− 11.2 and 84.6 +/− 9.3 respectively at six months. There was no statistically significant difference between groups. Conclusions. Arthrodesis of the 1. st. MTPJ with the Anchorage™ plate and compression screw gives excellent clinical and radiographic results. Preparation method does not affect early outcomes but may influence important technical points such as length of the first ray or inter-phalangeal angle