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

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

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

Introduction. Brachymetatarsia is a rare deformity affecting the toes and leading to functional and psychological impact. The main aim of the study is to assess the efficacy of the surgical callus distraction technique in terms of length achievement in the paediatric group. Secondary objectives are functional improvement, reported complications and overall duration of treatment. Materials and Methods. For the series of cases involving all paediatric patients who had surgical correction at our unit from 2014 until the present, the electronic records were accessed to collect data. Pre-, peri- and post-operative assessments and investigations were used to evaluate patients' progress. The final plain films obtained were used to calculate the overall length achieved. Results. Six patients (ten feet) have been identified since 2014 with 12 metatarsals being gradually lengthened by applying the callus distraction principle using MiniRail OrthoFix 100. The majority are females (n=5), all of whom were diagnosed with congenital brachymetatarsia, with the only male (n=1) being post-traumatic, while the mean age is 14.5 ±1.5. The treatment was successful in all cases, with an average duration between surgery and metal removal of 5.5 ±1.3 months. Gait lab analysis was performed in (n=2) patients as part of preoperative analysis supporting surgical intervention. Complications were reported in two toes, with one requiring a revision procedure for loss of tension at the osteotomy site, and the second having an infected MTPJ stabilising k-wire treated with oral antibiotics and planned removal. Conclusions. In the paediatric group, gradual MT lengthening surgery using the Mini Ex-Fix is an effective method to treat brachymetatarsia. Preoperative assessment, psychological support and preparation for the extended rehabilitation period are vital. Gait lab analysis is advised pre- as well as postoperatively and this is now our protocol for supporting surgical decision

Background. Salvage procedures on the 1. st. MTPJ following failed arthroplasty, arthrodesis or hallux valgus surgery are difficult and complicated by bone loss. This results in shortened first ray and transfer metatarsalgia. We present our experience of using tri-cortical interposition grafts to manage this challenging problem. Methods. Between 2002 and 2009 our department performed 21 1. st. MTPJ arthrodeses using a tri-cortical iliac crest interposition graft. Surgical fixation was achieved with a compact foot plate. We performed a retrospective review from the medical notes and radiographs along with American Foot and Ankle scores which were collected prospectively. We analysed the following parameters: time to radiological union, requirement for further surgery, lengthening of 1. st. ray and any post operative complications. Results. Patient demographics were Male: Female = 4:16 with a mean age of 58 years (38-78 years). Mean follow up was 35 months (4-94 months). Indications for surgery were failed arthroplasty 8, failed fusion 9, previous Keller's 1, failed Scarfe Osteotomy 1 and avascular necrosis 2. Arthrodesis was achieved in 18 patients (90%) at 4 months post-surgery (2-12 months). Mean AOFAS was 45 pre-op, 75 post-op. Lengthening of the 1. st. Ray was achieved with 6mm average (5mm - 10mm). There were 7 complications (35%), with 3 major (15%) – 2 non unions and 1 varus overcorrection and 4 minor (20%) – 2 superficial infection, 2 painful hardware. Conclusion. Using interposition arthrodesis for the salvage of 1. st. MTPJ surgery we achieved union in 90% of patients. However, the rate of complications is not low and hardware often causes irritation, requiring removal

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

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

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

Aims

To evaluate safety outcomes and patient satisfaction of the re-introduction of elective orthopaedic surgery on ‘green’ (non-COVID-19) sites during the COVID-19 pandemic.

Little information is available about several important aspects of the treatment of melioidosis osteomyelitis and septic arthritis.

We undertook a retrospective review of 50 patients with these conditions in an attempt to determine the effect of location of the disease, type of surgical intervention and duration of antibiotic treatment on outcome, particularly complications and relapse.

We found that there was a 27.5% risk of osteomyelitis of the adjacent bone in patients with septic arthritis in the lower limb. Patients with septic arthritis and osteomyelitis of an adjacent bone were in hospital significantly longer (p = 0.001), needed more operations (p = 0.031) and had a significantly higher rate of complications and re-presentation (p = 0.048).

More than half the patients (61%), most particularly those with multifocal bone and joint involvement, and those with septic arthritis and osteomyelitis of an adjacent bone who were treated operatively, needed more visits to theatre.

Cite this article: Bone Joint J 2015;97-B:277–82.