Introduction: Arthrodesis of 1st metatarsophalangeal joint is a reliable procedure for the treatment of symptomatic arthritis. Various techniques are in use to facilitate arthrodesis. We evaluated our results using a new and simple construct of two staples applied perpendicular to one another. Material and Methods: Prospective observational study. A total of 29 patients (26 females, 3 males), Mean age 59yrs. 34 Hallux MTP joint fusions, 5 of them bilateral. Pre-operative diagnosis was Osteoarthritis in 27 and Rheumatoid arthritis in 2. Technique: Medial incision, planar cuts using saw. Staples placed dorsoventrally and mediolaterally. Patients: were mobilised in heel weight bearing post op shoe for 4–6 weeks. All patients had regular clinical and radiological assessment. Mean followup was 24 months. Results: Pre-op mean AOFAS score was 31 (Modified AOFAS score, total value 90 Portion of MTP joint motion was not included). Post-op mean AOFAS (modified) score was 81. 26 patients were very satisfied with the outcome of surgery, 2 were satisfied with reservation and one patient was not satisfied. 28 out of 29 patients would recommend this procedure to others. Ability to wear shoes improved in 26, same in 2 and worse in one patient. There were two mal-unions, one superficial wound infection treated with antibiotics and 6 patients had prominent staples requiring removal. There was no radiological non-union. Conclusion: Our technique of 1st MTP joint arthrodesis using 2 staples applied perpendicular to each other provides a reliable and stable construct that does not require use of plaster post-operatively. This has resulted in painfree post-op period without any need for plaster thus saving time and avoiding complications of plaster i.e stiffness and DVT. We strongly recommend the use of this type of fixation

Background: We present a prospective two to ten year follow-up of soft tissue balancing surgery at the subluxated second MTP joint. The purpose of this study was to find out the effect of soft tissue balancing techniques of the second MTP joint on long term VAS and AOFAS results. As second hypotheses we compared the results of two different techniques, one group with additional transarticular Kirschner wire (KW) fixation of the second MTP joint temporary for 3 weeks postoperative and the other group without. Materials and Methods: Fifty-four patients, 45 women and nine men, with a total of 62 operative interventions were included in our follow-up evaluation. Soft tissue balancing techniques we used were capsulotomy, lengthening of the extensor tendons, incision of the collateral ligaments and intrinsic muscles with or without temporary transarticular Kirschner wire (KW) fixation. Pre- und postoperative VAS and AOFAS scores, as well as clinical and radiological findings were analyzed. One weightbearing and one without weightbearing dorsoplantar radiograph as well as a 45 degrees rotated radiograph were done pre and postoperatively to proof the position of the second toe. Results: The statistical calculations showed a highly significant outcome (p< 0.0001) comparing pre- to postoperative scores. Explorative data analysis as well as chi-square tests comparing the two groups - 29 second toes with and 33 second toes without temporarily additional transarticular KW fixation of the MTP joint - showed homogeneous distribution of all scores. Conclusion: Our evaluation showed highly significant improvement with soft tissue balancing for subluxated second MTP joint of the second metatarsal, but no benefit from additional KW fixation of the MTP joint

Introduction: Management of surgical failures of 1st MTP joint is complex. We present a series of 9 patients treated with bone block arthrodesis of the 1st MTP joint. Materials and Methods: 9 patients who underwent bone block arthrodesis of the hallux MTP joint over a three year period were retrospectively identified. Most of the patients had failed fusions and kellers arthroplasty. All 9 patients had pain and deformity of the hallux, 8 patients had limitation of mobility and 6 patients had gait and shoe wear problems. All patients underwent 1st MTP arthrodesis with interpositional tricortical bone blocks, to restore 1st ray length, with additional cancellous bone graft used in three patients. The construct was held with K-wires which were buried under the skin. 3 patients were put in plaster postoperatively. Results: The average age of the patients was 59 years with average follow up of 15 months. The hallux MTP score postoperatively was 78 out of the possible 90. The 1st MTP joint angle improved from 29.17 to 15.33. All the nine patients were satisfied (four rated it excellent and five rated it good) with their outcome, of which six would readily undergo similar operation and three would undergo the operation if there was no other option. Postoperative complications were mostly metalware related with 8 patients having shoe wear problems for which they underwent K-wire removal (usually under a local anaesthetic in the clinic). 4 patients had minor paraesthesia, 3 patients had superficial infection treated with antibiotics and 1 patient had persistent non-union (but was pain free). Conclusion: The results with bone block arthrodesis are satisfactory and have added advantage of restoring the length of the 1st ray

Aim: Myerson and Sheriff described an anatomical basis for the correction of hammertoe deformity. Based on this model we performed a metatarsophalangeal soft tissue release and proximal interphalangeal arthroplasty. Method: Patients operated between March 1995 and January 2000 were retrospectively reviewed using the American Orthopaedic Foot and Ankle Society Scores (AOFAS) by independent assessors. Results: There were 84 patients with 99 feet and 179 hammertoes with a median follow-up of 28 months. The median AOFAS score was 83 and 87% of patients had a score of more than 60 points. Eighty-three percent of patients were satisþed while 17% were dissatisþed with the procedure. Pain at the metatarsophalangeal joint was the commonest cause of dissatisfaction with 14% having moderate or severe pain. Only 2.5% had metatarsophalangeal joint instability and 9% had callus formation. There was no statistical difference regarding the age and sex of the patient, number of toes operated on, associated hallux valgus surgery and follow-up of less than or greater than 2 years. Conclusions: This study is based on an anatomical model and shows a good result with no recurrence of hammertoe correction

The first metatarsophalangeal (MTP) joint is the key joint of the foot in terms of function during gait. Various replacement toe joint prostheses are commercially available but unlike other replacement joints such as the hip or knee, few simulator based studies have been conducted to evaluate the performance and reliability of these prostheses. Presented are results obtained using a newly developed and validated multi-station MTP joint test-rig that is able to simulate the natural biomechanics of the toe joint. The developed simulator is a multi-station computer controlled electro-pneumatic metataso-phalangeal joint simulator that applies dynamic loading and motions commensurate with the walking gait cycle. This involves the combination of plantar-dorsi flexion range of 32 degrees, 5 degrees of inversion/eversion and toe-off dynamic loading peaking at up to 820 N. Presented are the validation and in vitro test results of MTP joint simulations carried out on silastic and articulating metal and polymer designs of MTP prostheses. Despite being subjected to a reduced loading regime of 300 N peak force, the silastic prostheses were found to perform poorly in the simulator, ultimately failing due to a combination of fatigue crack growth and joint collapse. This behaviour and failure mode was consistent with that of ex vivo origin silastic MTP prostheses examined and provides confidence in the validity of the simulator

Between March 1995 and January 2000 we reviewed retrospectively 84 patients with hammer-toe deformity (99 feet; 179 toes) who had undergone metatarsophalangeal soft-tissue release and proximal interphalangeal arthroplasty. The median follow-up was 28 months. Patients were assessed by the American Orthopaedic Foot and Ankle Society Scores (AOFAS) and reviewed by independent assessors. The median AOFAS score was 83, with 87% of patients having a score of more than 60 points; 83% were satisfied and 17% were dissatisfied with the procedure. Pain at the metatarsophalangeal joint was the commonest cause of dissatisfaction, with 14% having moderate or severe pain. Only 2.5% had instability and 9% had formation of callus. There was no statistical difference for the age and gender of the patients, the number of toes operated on, associated surgery for hallux valgus or length of follow-up. Our study was based on an anatomical model and shows good results with no recurrence of deformity

Total joint arthroplasty of the first metatarsophalangeal joint is an acceptable modality of treatment for hallux rigidus. We set out to evaluate the early outcome of ceramic/ceramic (MOJE) prosthesis, in the treatment of painful hallux rigidus. Between March 2000 and June 2002, 13 patients (14 implants) with painful hallux rigidus were treated with ceramic/ceramic (MOJE) prosthesis. The hallux meta-tarsophalangeal-interphalangeal scoring scale, by the American Orthopaedic Foot and Ankle Society, was used to assess these patients, pre-operatively and at follow up. A total score of 100 is possible in a patient with no pain, full range of MTP joint movement and good alignment. The average follow up was for 12 months. At six months, 12 patients had no pain post operatively. The average AOFAS score pre-operatively was 43.07, compared to 95.28 post-operatively (p= 0.0001). Ten of the patients subjectively described the out come of the procedure as excellent. Two patients described it as satisfactory. One patient with significant hallux valgus pre-operatively, developed subluxation of the prosthesis at 6 months. At revision, the prosthesis was noted to be loose and a distraction arthrodesis was carried out. Pre-operatively, all patients had a combined dorsiflexion and plantarflexion range of between 30 and 74 degrees. Post operatively this was improved to greater than 75 degrees in 10 patients. Seven out of the eight female patients were able to wear fashionable foot shoes with high heels comfortably. Twelve of the patients experienced audible squeaking, which improved after six months. One patient developed a superficial infection, which was treated successfully. The ceramic/ceramic (MOJE) total arthroplasty gave excellent results in 77% of patients. Patients were happy with the fact that they could continue wearing fashionable shoes. The early outcome is encouraging, with a statistically significant improvement in the AOFAS scoring system

Background. As hallux valgus (HV) worsens clinical and radiological signs of arthritis develop in metatarsophalangeal joint due to incongruity of joint surfaces. The purpose of this prospective study was to determine if intraoperative mapping of articular erosion of the first metatarsal head, base of the proximal phalanx, and tibial and fibular sesamoids can be correlated to clinical and/or radiographic parameters used during the preoperative assessment of the HV deformity. Materials and methods. We analysed 50 patients prospectively who underwent surgery between Jan 2009-Jan 2010. Patients with a known history of previous first metatarsophalangeal joint surgical intervention, trauma, or systemic arthritis were excluded from analysis. Preoperative demographics and AOFAS score were recorded. Intraoperative evaluation and quantification of the first metatarsal head, base of the proximal phalanx, and sesamoid articular cartilage erosion was performed. Cartilage wear was documented using International Cartilage Research Society grading. Results and Discussion. P. Bock et al have showed that the extent of cartilage lesions were clearly correlated with the degree of hallux valgus angle proving that a malaligned joint is more prone to cartilage degeneration. Kristen et al have described a correlation between a higher pre-operative hallux valgus angle and the post-operative Kitaoka et al score. The higher the preoperative hallux valgus angle, the lower the post-operative score. Our series showed the mean IMA is 15 degrees. The mean AOFAS score was 62. There was a significant positive correlation between hallux valgus angle and AOFAS score. We also found correlation between sesamoid wear and AOFAS score and HV angle. Conclusion. We conclude that preoperative clinical parameters (ie, age) and radiographic measurements (ie, HV, IMA) directly define the incidence and location of articular erosion and are helpful in the preoperative assessment of the HV deformity

It is recognised that as the severity of hallux valgus (HV) worsens, so do the clinical and radiological signs of arthritis in the first metatarsophalangeal joint. However, few studies specifically document the degenerate changes. The purpose of this study is to determine if intraoperative mapping of articular erosive lesions of the first MTP joint can be correlated to clinical and/or radiographic parameters used during the preoperative assessment of the HV deformity. Materials & Methods. We prospectively analysed 50 patients who underwent surgery between Jan 2009 & Jan 2010. Patients with a known history of previous first metatarsophalangeal joint surgical intervention, trauma, or systemic arthritis were excluded from analysis. Preoperative demographics and AOFAS scores were recorded. Radiographic measurements were obtained from weight bearing radiographs. Intraoperative evaluation of the first metatarsal head, base of the proximal phalanx, and sesamoid articular cartilage erosion was performed. Cartilage wear was documented using International Cartilage Research Society grading. Results. three patients did not have scoring or cartilage wear documentation carried out and were excluded. The mean age was 56 years. The mean hallux valgus angle was 31 degrees. The mean IMA was 15 degrees. The mean AOFAS score was 62. Patients with no inferomedial (IM) and inferolateral (IL) wear had significantly better AOFAS score than patients who had IM & IL wear (p < 0.05). Patients who had IM & IL wear had a significantly higher HVA (p < 0.05). There was a significant positive correlation between hallux valgus angle and AOFAS score. We also found correlation between sesamoid wear and AOFAS score and HV angle. Conclusion. we conclude that preoperative clinical and radiographic measurements can be used to predict the incidence and location of articular erosions in the 1st MTPJ and are helpful in the preoperative assessment of the HV deformity

Introduction: The foot is a very complex structure acting as the platform for all gait patterns. At present, little is known about the exact biomechanics of the foot due to the difficulties in modeling all of the components of the foot accurately. This has made it virtually impossible to develop a complete understanding of the aetiology of many diseases of the foot including hallux rigidus. We hypothesize that sagittal plane incongruency of the rotation of the 1. st. Metatarsophalangeal Joint (MTPJ), or an increase in the tension of the intrinsic plantar flexors is responsible for the development of hallux rigidus. Materials & Methods: Ground reaction forces and kinematic data from gait analysis together with anthropometric data from MRI scans of a 24 y.o. female were used to create a Mimics model of the articulation of a normal 1st MTPJ during a gait cycle. The centre of rotation was calculated by triangulating the articular surfaces. Finite element analysis was performed on the model and on similar models with the hypothesized;. joint incongruency,. an increased tension in the Flexor Hallicus Brevis and. an increased tension in the plantar fascia. Results: The results demonstrated a significant increase in the peak stresses, contact areas and stress distributions between the incongruent models compared to the congruent models. Discussion: To the best of our knowledge this is the most accurate FE model of the 1st MTPJ calculated. Hallux Rigidus is a very common forefoot disorder, with multiple etiologies and treatments advocated. This model demonstrates that an increased tension in the plantar flexors results in a reduced ROM with increased contact stresses on the joint surface. Conclusion: While it is known Hallux Rigidus has a multi-factorial etiology, the authors feel the above study demonstrates an important inherent etiology

Hallux rigidus was first described in 1887. Many aetiological factors have been postulated, but none has been supported by scientific evidence. We have examined the static and dynamic imbalances in the first metatarsophalangeal joint which we postulated could be the cause of this condition. We performed a finite-element analysis study on a male subject and calculated a mathematical model of the joint when subjected to both normal and abnormal physiological loads.

The results gave statistically significant evidence for an increase in tension of the plantar fascia as the cause of abnormal stress on the articular cartilage rather than mismatch of the articular surfaces or subclinical muscle contractures. Our study indicated a clinical potential cause of hallux rigidus and challenged the many aetiological theories. It could influence the choice of surgical procedure for the treatment of early grades of hallux rigidus.

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.

In five years 55 joints in 46 patients were treated surgically with a titanium implant for arthritic hallux meta-tarsophalangeal joints. There were 35 women and 11 men. The pathological indications were hallux rigidus (74%), rheumatoid arthritis (10%) and degenerative changes associated with hallux valgus (16%). Six cases were done as a revision of silastic to titanium prosthesis due to severe silicone synovitis.

The mean age was 60 (range 43–76) years, and the mean follow up was 56 (range 28–86) months. The mean time taken to get back to normal activities is 36 (range 21–90) days. The mean range of motion achieved was 32 degrees (range 20–64) and the relief of pain was excellent or good in 86% of the patients. There were no surgical complications in the form of infection, osteolysis or instability. The synovitis in the revision group has subsided.

The clinical results of titanium hemiarthroplasty were good. The advantages of this procedure were preservation of joint movement and good pain relief.

Introduction

The attachment of the plantar aponeurosis to the proximal phalanx of the toe, through the plantar plate (PP), forms the main flexor of the toe during gait by the reversed windlass mechanism. Disruption of the plantar plate is a common cause of pain, instability and toe deformity. Surgical techniques have recently been described to repair tears but long term results are awaited. This study aims to review the results of a technique designed to reconstruct and reinforce the failed plantar plate and restore the reversed windlass.

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.

25 First metatarso phalangeal joint replacements using the MOJE implant were prospectively assessed. There were 13 females and 10 males, with an average age of 60 years (range 45–71 years). The main indication for surgery was a symptomatic Hallux Rigidus.

The minimum follow up period was 2 years (range 24–38 months). The patients were assessed before and after surgery using the AOFAS (American Orthopaedic Foot and Ankle Society Hallux Score). The mean pre operative AOFAS score was 45.60 and this improved to 85.63 after surgery. There was a significant improvement in the sub scale for pain, from 4.58 pre operatively to 31.25 post operatively. A 9.5⁰ improvement in the range of motion was noted.

The authors conclude that their study demonstrates that the use of the MOJE implant for the treatment of Hallux Rigidus is a safe and useful option, although a more long term follow up is indicated.

Background: The painful 1st metatarso-phalangeal joint (MTPJ) is a common presentation in outpatient clinics. Options for treatment include arthroplasty and arthrodesis. Previous MTPJ replacement implant designs have had poor mid-term success. The Moje prosthesis was designed to overcome some of the problems with earlier implants, and employs ceramic bearing surfaces and a press-fit tapered stem design. Previous studies have reported good early results in small numbers of patients.

Methods: Between February 2002 and December 2006 the senior author implanted 55 components in 48 patients. AOFAS hallux scores and satisfaction scores (0 to 10) were recorded at follow-up. Radiographs were analysed for component alignment, implant bone coverage and subsidence. The mean age of patients at implantation was 56 years (34–77). Average follow-up was 42 months (15 to 74).

Results: There were no patients lost to follow-up. Average AOFAS score was 72 (25 to 100) and satisfaction score was 8.2 (range 1 to 10). 82% stated they would have the same procedure again and 82% reported minimal or no pain. There were no deep infections but 35% of patients reported altered sensation. Four implants have been removed (8%) because of worsening pain and implant loosening. 50% of metatarsal implants and 80% of phalangeal implants were implanted within 5 degrees of the long bony axis. Average bony coverage was 80%, resulting in subsidence of 90% of metatarsal and 70% of phalangeal implants at follow-up.

Discussion: Despite the poor radiographic appearance in the majority of cases, this procedure has good clinical outcome at the mid-term stage with 92% implant survival. The long-term clinical significance of the radiographic appearances is currently unknown. Improved surgical technique, including better bony coverage, may reduce the risk of implant subsidence.