Relationship between clinical measurements and motion of the first metatarsophalangeal joint during gait

BACKGROUND: The range of joint motion is a commonly reported outcome measure in assessment of the great toe. Although motion of the first metatarsophalangeal joint during gait is of primary functional importance, clinicians rely on relatively static clinical measures to assess this joint. The relationship between the results of commonly used clinical tests of motion of the first metatarsophalangeal joint and motion of this joint during gait was assessed in a study of thirty-three subjects who had no history of a pathological condition of the foot or ankle. METHODS: An electromagnetic tracking device was used to acquire three-dimensional orientation data on the hallux with respect to the first metatarsal. Receivers were secured to the skin overlying the proximal phalanx of the hallux, the first metatarsal, and the medial aspect of the calcaneus. Measurements were recorded during four clinical tests. These tests assessed the active range of motion of the first metatarsophalangeal joint with the subject weight-bearing, the passive range of motion with the subject weight-bearing, the passive range of motion with the subject non-weight-bearing, and the motion during a heel-rise. The data collected with these tests were compared with motion of the first metatarsophalangeal joint during walking. The focus of the analysis was the dorsiflexion component of rotation. RESULTS: With the exception of the passive range of motion with the subject weight-bearing, the ranges of motion measured during all of the clinical tests exceeded the motion of the first metatarsal joint that is required during normal walking. The motion measured during heel-rise (r = 0.87, p < 0.001) and the active range of motion with the subject weight-bearing (r = 0.80, p < 0.001) had the strongest correlations with motion of the first metatarsophalangeal joint during gait. The mean dorsiflexion during the test of the active range of motion (44 degrees) was closer to the mean dorsiflexion during gait (42 degrees) than was the mean value measured during the heel-rise test (58 degrees). This study also demonstrated that the clinical tests are not interchangeable as their mean results differed by as much as 21 degrees. CONCLUSIONS: The selection of a reliable and valid clinical test and an understanding of the relationship of the results of this test to the motion requirements during normal gait will help to standardize reporting techniques and will improve the ability of the clinician to determine the outcomes of treatment. This study showed that measurement of the active range of motion with the subject weight-bearing was a reliable and valid test and that the results were strongly correlated with motion of the first metatarsophalangeal joint during gait.     

The influence of first ray mobility on forefoot plantar pressure and hindfoot kinematics during walking

BACKGROUND: Hypomobility and hypermobility of the first ray have been implicated in the literature as a primary cause of mechanical foot problems because of proposed obligatory and compensatory movements. Despite these theoretical links, research is sparse regarding the effect on kinematic and plantar pressure patterns as a result of altered first ray mobility. The purpose of this study was to determine whether hypomobility or hypermobility of the first ray alters hindfoot kinematics or the distribution of plantar pressures during walking. METHODS: The magnitude of dorsal first ray mobility in 82 individuals was measured and then classified as being hypomobile, normal, or hypermobile. The plantar pressure under the first and second metatarsal heads, as well as hindfoot kinematics during walking, were then compared between the three categories of first ray mobility. RESULTS: The results of this study indicate that those feet with a hypomobile first ray had significantly decreased plantar force and pressure values under the first metatarsal compared to the second metatarsal. In addition, feet with a hypomobile first ray showed significantly more hindfoot eversion compared to those with either normal or hypermobile first rays. CONCLUSION: The results of this study do not support the common theoretical implications of altered mobility of the first ray related to plantar pressure and hindfoot kinematics.     

Complications of midfoot and hindfoot arthrodesis

Midfoot and hindfoot arthrodeses traditionally have been done to treat deformities resulting from paralytic disorders, residual clubfoot deformity, and posttraumatic arthritis. The surgical indications for midfoot and hindfoot arthrodeses more recently have been expanded to include painful arthritic deformities associated with neuroarthropathy, seropositive or seronegative arthropathies, and neurologic disorders. Regardless of the joint fused or the technique used, the goal of each remains similar: the creation of a painless, plantigrade foot capable of being fitted into, at the very least, a custom shoe. The aim of the current study is to describe the major complications associated with midfoot and hindfoot fusions in adults, and the prevention and the treatment of these complications.     

Inter-relationship between rearfoot and midfoot frontal plane motion during walking

BackgroundBecause of the complex nature of foot motion during locomotion, the relationship between the rearfoot and midfoot warrants additional investigation.ObjectiveExplore the relationship between frontal plane motion of the rearfoot and midfoot during the stance phase of walking.MethodUsing an electromagnetic motion analysis system, the frontal plane motion of the rearfoot and midfoot of 153 individuals (55 men, 98 women) were collected. The resulting motion patterns for each segment of the foot were then correlated to determine if all subjects exhibited the same relationship between the two segments. Those subjects with a statistically significant negative correlation between the rearfoot and midfoot were then compared on eight rearfoot variables with the group of subjects with a statistically significant positive correlation.ResultsThe mean correlation between the rearfoot and midfoot segments was found to be −.307 with a standard deviation of .094. Counter-rotation between the rearfoot and midfoot segments was not seen in 18.9% of the subjects.ConclusionsThis study indicates that a significant group of individuals do not demonstrate the typical counter-rotation pattern of motion between the rearfoot and midfoot during walking. Possible reasons for and the likely clinical implications of this atypical motion pattern are discussed.     

Tenotomy and tendon transfer about the forefoot, midfoot and hindfoot

Tendon lengthening and transfer are essential surgical procedures for every foot and ankle surgeon to master, because they are useful in restoring balance and correcting flexible foot deformities. These techniques are even more useful in treating the high-risk patient, because they involve minimal soft-tissue injury and maximum preservation of vascularity. The primary goal of this article is to supplement the foot and ankle surgeon's options for treating static and dynamic foot deformities in the high-risk patient by discussing useful tendon lengthening and transfer procedures about the forefoot, midfoot, and hindfoot.     

Percutaneous fixation of forefoot, midfoot, hindfoot, and ankle fracture dislocations

Open reduction with rigid internal fixation is the basic principle for surgical management in foot and ankle trauma. High-risk patients present a surgical dilemma for the foot and ankle surgeon because the possible complications are magnified in this patient population. Percutaneous fixation is a unique alternative for achieving anatomic stabilization without increased physical strain to the patient. The significant advantages of percutaneous fixation include minimizing damage to the vascular supply, maintaining and preserving a stable soft tissue envelope, and decreasing the potential risk for infection. This article provides an overview of percutaneous surgical fixation methods and their role in foot and ankle trauma for the high-risk patient.     

Outcomes of midfoot and hindfoot fractures in multitrauma patients

Introduction

Multitrauma patients suffering hindfoot fractures, including calcaneal and talar fractures, often result in poor outcomes. However, less is known about the outcomes following midfoot fracture in the mutitrauma population. This study aims to describe the epidemiology of midfoot fractures in multitrauma patients and to compare the outcomes of midfoot and hindfoot fractures in this population.

Minimally invasive surgery and percutaneous surgery of the hindfoot and midfoot

Minimally invasive surgery (MIS) and percutaneous (PC) surgery recently spread as a new technique in operative forefoot correction, and by extension in hindfoot and midfoot. Numerous procedures were described, and a race for MIS and PC has started. However, performing surgery with small incisions should not be an end in itself. Biomechanical and anatomical concerns must be taken into account and shall not be sacrificed for cosmetic reasons. For the most common hindfoot and midfoot pathologies, we discuss what we consider the surgical necessities and then describe the MIS and/or PC procedure we choose, according to these fundamentals.     

The relationship between forefoot, midfoot, and rearfoot static alignment in pain-free individuals

STUDY DESIGN: Correlational study. OBJECTIVES: To determine whether, and to what degree, a relationship exists between forefoot angle and weight-bearing midfoot and rearfoot position. BACKGROUND: There have been conflicting reports with regard to the degree to which the structure of the foot may influence the function. The influence of forefoot structure on weight-bearing midfoot and rearfoot position has not been extensively investigated. METHODS AND MEASURES: Fifty-one healthy subjects participated in this study (26 male and 25 female). Forefoot angle was measured in prone as varus (positive numbers), neutral (0), or valgus (negative numbers). Navicular drop was measured from subtalar joint neutral to unilateral standing relaxed. Rearfoot angle was measured in relaxed single-limb stance as the angle between a line that bisected the calcaneus and a line that bisected the lower third of the leg. The relationships between forefoot angle and navicular drop, and between forefoot angle and relaxed rearfoot angle, were investigated. The same relationships were also investigated in the neutral forefoot subgroup when the sample was divided in 3 subgroups based on 1 standard deviation of forefoot angle. RESULTS: There is a significant relationship between forefoot angle and relaxed rearfoot angle (r = 0.52, P < .001), as well as between forefoot angle and navicular drop (r = 0.55, P < .001), in the whole sample (n = 51). Average degrees of forefoot angle in the neutral subgroup (between 1.0 degree and 8 degrees of varus) are not associated with predictable positions of relaxed rearfoot angle (r = 0.19, P = .24) or navicular drop (r = 0.01, P = .96). CONCLUSIONS: Based on the results of this study, there is a significant relationship between forefoot angle and relaxed rearfoot angle, as well as between forefoot angle and navicular drop, in healthy subjects. These relationships were not found when forefoot varus values were within a standard deviation of the sample mean.     

Non-irradiated frozen structural allograft in reconstructive surgeries of the hindfoot and midfoot

BackgroundA few studies investigating the use of structural allograft in foot and ankle surgery are available. The purpose of this study is to analyze the clinical, functional and radiological results of patients treated with non-irradiated frozen structural bone allograft.MethodsWe analyzed 20 reconstructive surgeries of the hindfoot and midfoot performed between April 2004 and April 2010. The mean follow up period was 45.4 months. The results were evaluated according to AOFAS score, X-ray (allograft consolidation, alignment preservation, and allograft collapse or re-absorption), and complications.ResultsWe observed a 48-point mean improvement of AOFAS ankle and hindfoot score (17 cases), and a 53-point mean improvement of AOFAS midfoot score (3 cases). The mean bone consolidation time was 75 days. No graft fracture and no cases of non-union were seen.ConclusionThis treatment is a good option to treat severe defects or fill sequelae deformities.     

Deformity and degeneration in the hindfoot and midfoot joints of the adult acquired flatfoot

Adult acquired flatfoot is generally characterized by loss of the longitudinal arch, hindfoot valgus, and forefoot abduction, but the precise deformity has not been adequately described at the level of individual joints. Simulated weightbearing CT scans and plain radiographs of 37 symptomatic flat feet were examined in this study. The degree of arthritic degeneration was assessed in the major hindfoot and midfoot joints, and the location of deformity was studied along the medial column of the arch. Moderate to severe degeneration was seen in about one-third of talonavicular, subtalar, and calcaneocuboid joints. The medial column of the arch collapsed through the talonavicular joint in some feet, through the medial naviculocuneiform joint in others, but rarely through both. First tarsometatarsal joint subluxation was a frequent finding as well. In this small series, neither the degree of degenerative arthritis nor the amount of joint deformity was seen to correlate with patient age. Furthermore, no correlation was observed between foot deformity and joint degeneration.     

Hallux valgus and first ray mobility: a cadaveric study

BACKGROUND: Several studies have demonstrated that patients with hallux valgus (HV) deformities have increased first ray sagittal mobility. However, the change in mobility that occurs after surgical correction of HV deformities has not been extensively evaluated. This study was done to determine if surgical realignment of the first ray in cadaver specimens with a proximal crescentic osteotomy and distal soft tissue reconstruction (DSTR) would reduce the first ray sagittal motion as measured with an external-type micrometer (the Klaue device). METHODS: Twelve fresh-frozen below-knee cadaver specimens with an HV deformity (HV angle > 15 degrees, 1-2 IM angle > 9 degrees) were used for the study. Standardized simulated weightbearing radiographs were obtained before and after the surgical correction of the deformity. The first ray sagittal motion was measured with an external micrometer (Klaue device) before correction of the HV deformity and after the procedure. All specimens had correction of the hallux valgus deformity with a DSTR and proximal crescentic osteotomy. Internal fixation was applied to secure the osteotomy site. RESULTS: The HV angle was corrected from a mean of 28.6 degrees to a mean of 11.0 degrees. The 1-2 IM angle was corrected from a mean of 12.9 degrees to a mean of 6.8 degrees. The average preoperative first ray sagittal motion was 11.0 mm (range, 8.5 mm to 13.5 mm). After the surgical repair, the mean sagittal first ray motion was significantly decreased (p <.0005) to a mean of 5.2 mm (range, 3.5 mm to 7.5 mm). CONCLUSION: After correction of HV deformities with a DSTR and a proximal crescentic osteotomy, first ray mobility in cadaver specimens was significantly reduced. The stabilization of first ray mobility that occurred immediately after surgical correction despite leaving the capsule of the first metatarsocuneiform (MC) joint undisturbed suggests that extrinsic anatomic features may play a role in first ray mobility. Additionally, stability of the first ray may be restored with a bunion procedure that does not sacrifice the first MC joint.     

Hallux valgus and first ray mobility. A prospective study

BACKGROUND: There have been few prospective studies that have documented the outcome of surgical treatment of hallux valgus deformities. The purpose of this investigation was to evaluate the effect of operative treatment of hallux valgus with use of a proximal crescentic osteotomy and distal soft-tissue repair on the first metatarsophalangeal joint. METHODS: All adult patients in whom moderate or severe subluxated hallux valgus deformities had been treated with surgical repair between September 1999 and May 2002 were initially enrolled in the study. Those who had a hallux valgus deformity treated with a proximal crescentic osteotomy and distal soft-tissue reconstruction (and optional Akin phalangeal osteotomy) were then invited to return for a follow-up evaluation at a minimum of two years after surgery. Outcomes were assessed by a comparison of preoperative and postoperative pain and American Orthopaedic Foot and Ankle Society scores; objective measurements included ankle range of motion, Harris mat imprints, mobility of the first ray (assessed with use of a validated calibrated device), and radiographic angular measurements. RESULTS: Of the 108 patients (127 feet), five patients (five feet) were unavailable for follow-up, leaving 103 patients (122 feet) with a diagnosis of moderate or severe primary hallux valgus who returned for the final evaluation. The mean duration of follow-up after the surgical repair was twenty-seven months. The mean pain score improved from 6.5 points preoperatively to 1.1 points following surgery. The mean American Orthopaedic Foot and Ankle Society score improved from 57 points preoperatively to 91 points postoperatively. One hundred and fourteen feet (93%) were rated as having good or excellent results following surgery. Twenty-three feet demonstrated increased mobility of the first ray prior to surgery, and only two feet did so following the bunion surgery. The mean hallux valgus angle diminished from 30 degrees preoperatively to 10 degrees postoperatively, and the mean first-second intermetatarsal angle decreased from 14.5 degrees preoperatively to 5.4 degrees postoperatively. Plantar gapping at the first metatarsocuneiform joint was observed in the preoperative weight-bearing lateral radiographs of twenty-eight (23%) of 122 feet, and it had resolved in one-third (nine) of them after hallux valgus correction. Complications included recurrence in six feet. First ray mobility was not associated with plantar gapping. There was a correlation between preoperative mobility of the first ray and the preoperative hallux valgus (r = 0.178) and the first-second intermetatarsal angles (r = 0.181). No correlation was detected between restricted ankle dorsiflexion and the magnitude of the preoperative hallux valgus deformity, the post-operative hallux valgus deformity, or the magnitude of hallux valgus correction. CONCLUSIONS: A proximal crescentic osteotomy of the first metatarsal combined with distal soft-tissue realignment should be considered in the surgical management of moderate and severe subluxated hallux valgus deformities. First ray mobility was routinely reduced to a normal level without the need for an arthrodesis of the metatarsocuneiform joint. Plantar gapping is not a reliable radiographic indication of hypermobility of the first ray in the sagittal plane.     

A comparison of device measures of dorsal first ray mobility

BACKGROUND: Devices built by Glasoe and Klaue have been used in several studies to measure first ray mobility. Both devices measure sagittal motion of the first ray in a dorsal direction. The primary difference in the devices is the method of the load imposed. This study investigates whether first ray mobility measured with the Glasoe device is similar to the amount of mobility measured with the Klaue device. METHODS: Using the devices described by Glasoe and Klaue, dorsal first ray mobility was measured in 39 patients who had foot and ankle problems. Paired t-tests were computed to assess for differences between device measures of dorsal mobility. Intraclass correlation coefficient (ICC) and absolute difference values were computed to further assess the agreement in measures. RESULTS: Dorsal mobility measured with the Glasoe device averaged 4.9 mm (1.8 to 9.3 mm). Dorsal mobility measured with the Klaue device averaged 5.2 mm (2.5 to 8.5 mm). Paired t-tests (p = 0.12) revealed no significant difference in measures. An ICC of 0.70 and a mean absolute difference of 0.9 mm (SD 0.8) were found between the two clinical measures further suggesting agreement. CONCLUSION: Results indicated that the two devices possess similar diagnostic accuracy in the measurement of dorsal first ray mobility.     

Comparison of first ray dorsal mobility among different forefoot alignments

STUDY DESIGN: Experimental design using 1-way analysis of variance and regression analysis to test the influence of 3 forefoot alignments on the dorsal mobility of the first ray. OBJECTIVES: To determine the effect of forefoot alignment on the magnitude of first ray dorsal mobility to an imposed load and to describe any association between forefoot alignment and age on dorsal mobility of the first ray. BACKGROUND: Instability of the first ray has been implicated as a primary mechanical etiology of many foot problems. It has been proposed that a relationship exists between forefoot alignment and mobility of the first ray, with a varus aligned forefoot contributing to the development of an unstable first ray. METHODS AND MEASURES: Sixty female (n = 34) and male (n = 26) subjects aged 18-77 were assigned into valgus, neutral, and varus foot groups (20 per group) based on a clinical measurement of forefoot alignment. A load cell device measured dorsal mobility of the first ray under a standard load of 55 N. Within-day repeat measures were taken from a subsample of subjects. In addition to reliability analysis, analysis of variance and regression analyses tested the relationship between forefoot alignment, age and sex, and mobility of the first ray. RESULTS: The forefoot valgus group demonstrated significantly less dorsal mobility of the first ray than neutral or varus groups. The varus and neutral groups were not significantly different from one another. Forefoot alignment and sex were significant linear predictors (R2 = 0.40) of first ray dorsal mobility. Age had no significant association to dorsal mobility of the first ray. CONCLUSION: Subjects having a valgus aligned forefoot had less dorsal excursion of the first ray than subjects having a neutral aligned forefoot. This investigation provides evidence supporting a relationship between forefoot alignment and mobility of the first ray.     

Dorsal mobility and first ray stiffness in patients with diabetes mellitus

BACKGROUND: Limited joint mobility in diabetic patients has been identified as a risk factor in the development of plantar ulcers. We examined dorsal mobility and passive first ray stiffness in patients with diabetes and investigated the relationship between first ray mobility and ankle joint dorsiflexion. METHODS: Forty individuals were studied: 20 with diabetes (mean estimated duration of 16 +/- 10 years) and 20 matched controls. Dorsal first ray mobility was measured using a mechanical device. Force-vs-dorsal mobility displacement values were collected at 10 N increments to a load limit of 55 N. Ankle joint dorsiflexion motion was measured with a goniometer. The "prayer sign," a clinical indicator of limited joint mobility, was evaluated in each patient. Subjects were separated into the two groups for data analysis. RESULTS: Patients in the diabetic group had more stiffness and less dorsal first ray mobility than the control group (p <.05). In particular, patients with a positive prayer sign had significant first ray stiffness (p <.05). Patients with diabetes also had less ankle dorsiflexion (p <.05). CONCLUSION: Patients with diabetes have more stiffness and less first ray mobility and less ankle dorsiflexion than those without diabetes. The presence of a positive prayer sign correlates with stiffness and loss of first ray mobility. Soft-tissue stiffness may contribute to the development of foot ulcers in diabetic patients with neuropathy.     

The effect of ankle position on the exam for first ray mobility

PURPOSE: The clinical assessment of first ray motion in the sagittal plane, as originally described by Morton, is difficult to quantify. Different reports have shown inconsistent values and variability between the manual exam and examination using an external measuring device. The authors hypothesize that when performing a manual examination for evidence of increased first ray motion, the magnitude of first ray mobility varies as the position of ankle dorsiflexion/plantarflexion varies. METHODS: Using an external caliper (a modified Klaue device), the authors quantified first ray motion in reference to variable ankle positions in a group of normal patients, a group of patients with untreated moderate and severe hallux valgus, a group who had undergone a successful metatarsophalangeal joint arthrodesis for hallux valgus, and a small group who had previously undergone a plantar fasciectomy. A total of 119 feet (109 patients) were measured. In addition to first ray motion, radiographic data were compared between groups. RESULTS: With the ankle in the neutral dorsiflexion position, the mean first ray motion was 4.9 mm for the control group, 7.0 mm for the hallux valgus group, 4.4 mm for the metatarsophalangeal fusion group, and 7.7 mm for the plantar fasciectomy group. There was a significant decrease (p < .05) in first ray motion when the ankle was moved to the dorsiflexed position for all four groups. There was a significant increase in first ray motion when the ankle was moved to the plantarflexed position (p < .01) for all groups except the plantar fasciectomy group. No significant difference in first ray motion was observed for the plantar fasciectomy group between the neutral and plantarflexed ankle positions (p < .05). CONCLUSION: The exam for first ray mobility is influenced by the position of the ankle and may explain the discrepancy between the manual exam and measurement with an external device. Recommendations for the manual exam of first ray mobility are given.     

Evaluation and biomechanics of the first ray in the patient with limited motion

Adequate first ray function is essential to healthy human gait. Controversies still exist about aspects of human structure and function and many newer answers and theories have been proposed by a new generation of experts. Examples include the sagittal plane facilitation, tissue stress, and preferred movement pathway theories. This article also presents a summary of how to provide a thorough, detailed, and accurate first ray examination on the individual with limited motion. This article explores functional first ray mechanics in both a theoretic and biomechanical perspective, as well as a practical, hands-on examination perspective.     

Comparison of posterior-stabilized,cruciate-retaining,and medial-stabilized knee implant motion during gait

Accurate knowledge of knee joint motion is needed to evaluate the effects of implant design on functional performance and component wear. We conducted a randomized controlled trial to measure and compare 6-degree-of-freedom (6-DOF) kinematics and femoral condylar motion of posterior-stabilized (PS), cruciate-retaining (CR), and medial-stabilized (MS) knee implant designs for one cycle of walking. A mobile biplane X-ray imaging system was used to accurately measure 6-DOF tibiofemoral motion as patients implanted with PS (n = 23), CR (n = 25), or MS (n = 26) knees walked over ground at their self-selected speeds. Knee flexion angle did not differ significantly between the three designs. Relative movements of the femoral and tibial components were generally similar for PS and CR with significant differences observed only for anterior tibial drawer. Knee kinematic profiles measured for MS were appreciably different: external rotation and abduction of the tibia were increased while peak-to-peak anterior drawer was significantly reduced for MS compared with PS and CR. Anterior-posterior drawer and medial-lateral shift of the tibia were strongly coupled to internal-external rotation for MS, as was anterior-posterior translation of the contact center in the lateral compartment. MS exhibited the least amount of paradoxical anterior translation of the femur relative to the tibia during knee flexion. The joint center of rotation in the transverse plane was located in the lateral compartment for PS and CR and in the medial compartment for MS. Substantial differences were evident in 6-DOF knee kinematics between the healthy knee and all three prosthetic designs. Overall, knee kinematic profiles observed for MS resemble those of the healthy joint more closely than PS and CR.