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

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.

Abstract. Background. Multiple devices can stabilise the MTP joint for arthrodesis. The ideal implant should be easy to use, provide reproducible and high quality results, and ideally enable early rehabilitation to enable faster return to function, whilst lessening soft tissue irritation. We prospectively evaluated the combination of the IO-Fix (Extremity Medical, NJ, USA) device which consists of an intra-osseous post and lag screw that offers these features with full bearing of weight after surgery. Methods. 67 feet in 65 patients were treated over 31 months. After excluding patients lost to follow-up, undergoing revision arthrodesis, or concomitant first ray procedures, there were 54 feet in 52 patients available with a minimum 12 month follow-up with clinical and radiographic outcomes. All patients were treated using a similar operative technique with immediate bearing of weight in a rigid soled shoe. Results. The mean MOXFQ score improved from 46.4 (range 18 – 64) before surgery to 30.2 (range 0 – 54) at 6 months after surgery (p=0.02), and 18.4 (range 0 – 36) (p< 0.001) at latest follow-up. Arthrodesis across the MTP joint was achieved in 52 feet (96%), at a mean of 61 days (range 39–201). Non-union was observed in two feet; superficial wound infections in two feet; and metalwork impingement in three feet. Conclusions. In the largest reported series to date, the IO-Fix device achieved a union rate of 96% across the MTP joint when coupled with immediate bearing of weight. Significant improvements were seen in patient reported outcomes with low complication rates

Abstract. The aim is to describe the safety and efficacy of TAL in out-patient clinics when managing diabetic forefoot ulcers. Patients and Methods. Consecutive patients, who underwent TAL and had minimum 12m follow-up were analysed. Forceful dorsiflexion of ankle was avoided and patients were encouraged to walk in Total contact cast for 6-weeks and further 4-weeks in walking boot. Results. 142 feet in 126 patients underwent this procedure and 86 feet had minimum follow-up of 12m. None had wound related problems. Complete transection of the tendon was noted in 3 patients and one-patient developed callosity under the heel. Ulcers healed in 82 feet (96%) within 10 weeks however in 12 feet (10%), the ulcer recurred or failed to heal. MRI showed plantar flexed metatarsals with joint subluxation. The ulcer in this subgroup healed following proximal dorsal closing wedge osteotomy. Conclusion. Tightness of gastroc-soleus-Achilles complex and subluxed MTP joint from soft tissue changes due to motor neuropathy result in increased forefoot plantar pressures. A 2-stage approach as described result in long-term healing of forefoot ulcers, and in 96% of patients, the ulcer healed following TAL alone. TAL is a safe and effective out-patient procedure with improved patient satisfaction outcomes

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

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

Crossover second toe deformity is a multiplanar deformity derived from multiple etiologies with the common endpoint of metatarsophalangeal joint instability. The stability of the joint is compromised through laxity of the volar plate, secondary rupture of the lateral collateral ligament, and ultimately dorsal subluxation or dislocation of the metatarsophalangeal joint. The digital malalignment often includes a hammertoe deformity, but should not be confused with a routine clawtoe. Elimination of alternative diagnoses relies on precise palpation to negate Morton's neuroma, 2nd metatarsalgia, Freiberg's infraction, and 2nd metatarsal stress fracture. Radiographs assist in the diagnosis in not only eliminating the above mentioned differential diagnoses, but also in evaluating confounding anatomic variables such as hallux valgus, metatarsus primus varus, and metatarsal length. These variables may necessitate additional osteotomies in conjunction with ligament reconstruction to minimise recurrence. Operative intervention has revealed long term failure of secondary ligament reconstruction, mandating tendon transfers such as the flexor-to-extensor and the extensor digitorum brevis to support the repair. We will explore these techniques and subsequent modifications to achieve patient satisfaction

To evaluate the results of the reconstructive surgical treatment of complicated forms of infected osteoarthropathy with diabetic foot syndrome (DFS). The analysis of the results of the treatment of 58 patients with infectious complications of osteoarthropathy with the neuropathic form of the DFS, the average age 57.7+1.2 years. In 5 patients with Type I according to the Sanders & Frykberg classification, grade C according to the Roger classification of with neuropathic ulcers caused by deformation of the bones we employed corrective mini-osteotomy. In 32 patients with Type I, grade D with the infected ulcers associated with destruction of the metatarsal bones and the metatarsophalangeal joints, we performed the resection of the affected bones, subsequently filling the defects with antibiotic impregnated collagen sponge (AICS*), and then we closed the wound with primary suture. In 15 patients with Type II, grade D we performed the resection of the affected bones and stabilize the mid-foot using compressive screws and AICS. In 4 patients with Type III, grade D we perfomed the following resection of the affected bones we used AICS and the extrafocal corrective osteosynthesis using the Ilizarov's method. In 2 patients with Type IV+V, grade D we did an amputation using the Syme's technique and osteosynthesis using the Ilizarov's method. There was one case of septic instability of the compressive screw after more than one month: the screw was then removed; and there was one case of an unstable bone fragment: its removal was necessary. No recurrence of the trophic ulcers or osteomyelitis of the foot bones was observed during a 6 – 24 mounth follow-up in any other treated patients. The described methods are promising in the treatment of patients with DFS; their effectiveness can be evaluated after randomized trials will be completed

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

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

The saphenous nerve is classically described as innervating skin of the medial foot extending to the first MTP joint and thus is at risk in surgery to the medial ankle and forefoot. However, it has previously been demonstrated by the senior author that the dorsomedial branch of the superficial peroneal nerve consistently supplies the dorsomedial forefoot, leading to debate as to whether the saphenous nerve should routinely be included in ankle blocks for forefoot surgery. We undertook a cadaveric study to assess the presence and variability of the saphenous nerve. 29 feet were dissected from a level 10 cm above the medial malleolus, and distally to the termination of the saphenous nerve. In 24 specimens (83%), a saphenous nerve was present at the ankle joint. In 5 specimens the nerve terminated at the level of the ankle joint, and in 19 specimens the nerve extended to supply the skin distal to the ankle. At the ankle, the mean distance of the nerve from the tibialis anterior tendon and saphenous vein was 14mm and 3mm respectively. The mean distance reached in the foot was 5.1cm. 28% of specimens had a saphenous nerve that reached the first metatarsal and no specimens had a nerve that reached the great toe. The current study shows that the course of the saphenous nerve is highly variable, and when present usually terminates within 5cm of the ankle. The saphenous nerve is at risk in anteromedial arthroscopy portal placement, and should be included in local anaesthetic ankle blocks in forefoot surgery, as a significant proportion of nerves supply the medial forefoot

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.