The second ray syndrome: detailed pathological, clinical and therapeutic aspects

Summary The second ray syndrome, also known as the painful or overloading syndrome of the second ray or of the second metatarso-phalangeal joint, is on the anatomo-pathological plane a more or less complete lesion of the supporting plantar plate of the metatarsophalangeal joint. It consists of a painful instability of the second toe on its metatarsal head, as defined by Denis. This instability leads, after rupture of the plantar plate, to initially reducible and then progressively fixed and irreducible dislocation. The clinical features of the second ray syndrome are pain localised under the second metatarsal head, although the pain may equally involve the whole corresponding joint. There is a progressive development of plantar hyperkeratosis. Clawing of the second toe appears when the phalangeal base starts dislocating. The intrinsic factors leading to this syndrome correspond to an excess length of the second metatarsal. The extrinsic factors leading to it may aggravate the intrinsic causes or may act on their own. Medical treatment is only of value in the initial stage of syndrome. In the later stages surgical treatment involves the metatarso-phalangeal joint, the metatarsal, the toe and the extensor tendon in bony, joint and tendous stages of surgery. The need to involve all of these different sites arises from clinical and radiological assessment. Nevertheless, whatever technique is used, it is essential to shorten the second metatarsal and reduce and stabilise the metatarso-phalangeal joint, predisposing features such as hallux valgus should be treated where necessary.     

Surgical treatment approaches to second metatarsophalangeal joint pathology

The second metatarsophalangeal joint is prone to specific and varied pathology that is well understood and may exist in isolation or in combination with other forefoot abnormality. Surgical treatment options for managing end-stage second metatarsophalangeal abnormalities have been minimally studied and exist primarily in case studies and series in the literature. As a result, surgical approaches remain controversial and warrant further discussion.     

Salvage of first metatarsophalangeal joint arthroplasty complications

There are two broad categories of surgical techniques for first metatarsophalangeal joint arthroplasty. Resection arthroplasty is a resection of the base of the proximal phalanx with or without an interposition graft of capsule or adjacent tendon. The second technique involves a partial or complete joint replacement. The primary indication for these procedures is first metatarsophalangeal joint pain caused by arthritic change. The salvage surgical options for failed metatarsophalangeal joint arthoplasty are directed toward decreasing or eliminating the symptoms arising from the complications of these procedures.     

Gauthier's subcapital osteotomy in the treatment of metatarsophalangeal luxation of the 2nd ray. Apropos of 44 cases with 5 year followup

The authors report on a series of 44 metatarsophalangeal dislocations of the second ray which were treated surgically using Gauthier's technique. The patients were 44 middle-aged women. The surgical indication was a dislocation of the 2nd metatarsophalangeal joint with hallux valgus. There was excess length of the second metatarsal ray or acquired shortness of the first metatarsal. The treatment always included an osteotomy of the neck maintained by a transosseous pin. The average follow-up was 8 years and 3 months (minimum 5 years). Postoperative results were evaluated using clinical and radiological criteria. Surgical treatment gave 68.2% very good and good results and 4 recurrences of dislocation. The results in this series are identical with those in other series reported, but the backward displacement of the head of second metatarsal was found to be limited. Weil's osteotomy seems to provide better results because it better restores the relative lengths of the metatarsals and often makes interphalangeal arthroplasty unnecessary. Gauthier's metatarsal osteotomy is an easy procedure which effectively improves static metatarsalgia, but it provides limited metatarsal shortening. Weil's osteotomy is preferable in cases with long lateral metatarsals.     

Second metatarsophalangeal joint arthrography: A cadaveric correlation study

Arthrography of the second metatarsophalangeal joint is an important diagnostic tool to evaluate the integrity of the plantar plate and to aid in the decision process for surgical intervention. A variety of filling patterns have been identified with lesser metatarsophalangeal joint arthrography and their significance with soft-tissue pathology remains to be completely understood. The purpose of this cadaveric study was to evaluate dye patterns in a series of arthrograms of the second metatarsophalangeal joint and to correlate them with identifiable anatomic lesions or structural variants. Thirty-nine cadaveric specimens (including 28 matched pairs) underwent second metatarsophalangeal joint arthrography with a colored radiopaque dye. Arthrographic findings were observed and recorded. Specimens exhibiting dye extravasation outside of the capsular constraints of the joint were dissected to discover any soft-tissue abnormalities. Twenty-one percent of specimens exhibited abnormal extravasation of dye outside of the joint capsule. A plantar plate tear was identified in 2 of these specimens. Filling of the first intermetatarsophalangeal bursa occurred in 6 specimens. However, because this finding was identified in 2 matched pairs, an anatomic variance is suggested rather than a pathologic entity. This cadaveric study shows that anatomic variances exist concerning the second metatarsophalangeal capsule and that arthrography should be correlated with the clinical scenario.     

Joint-preserving surgery in rheumatoid forefoot: preliminary study with more-than-two-year follow-up

The authors propose a joint-preserving surgery for rheumatoid forefoot deformities as an alternative to the "classic" surgical approach to the rheumatoid forefoot. The main principle is joint preservation by shortening osteotomies of all the metatarsals performed at the primary location of the rheumatoid forefoot lesions, namely the metatarsophalangeal (MTP) joints and metatarsal heads. A scarf osteotomy is normally performed on the first ray. A Weil osteotomy is performed on the lesser metatarsals. Excellent correction of the hallux valgus deformity in the rheumatoid forefoot can be achieved with a scarf osteotomy in 92% of cases without the need for MTP joint arthrodesis. Similarly, 86% of the lateral metatarsal heads can be preserved using Weil osteotomies.     

You,the great toe of this assembly?

We report a case of unilateral pre-axial polydactyly of metatarsal type which was incompletely managed. Our patient was a 5-year-old boy with a primary first ray (M1) which was distally short and not making the metatarsophalangeal joint. In addition, there was a proximally hypoplastic lateral accessory ray forming the metatarsophalangeal joint. There was some involvement of the first tarsometatarsal joint. Clinically, there was no leg-length discrepancy or any evidence of anterolateral tibial bowing. The management involved reconstruction of the first ray by fusing the primary M1 with the accessory metatarsal. Furthermore, a subsequent lengthening SCARF osteotomy with bone grafting was also used to normalize the contour of the growing foot. The importance of knowledge of epiphyseal anatomy of the foot in planning the surgical management of such cases cannot be over-emphasized.     

Sliding oblique osteotomy for the treatment of hallux abducto valgus associated with functional hallux limitus.

This is a retrospective study of 27 patients (35 feet) with hallux abducto valgus associated with hallux limitus who underwent a sliding oblique osteotomy for surgical treatment between August 1997 and June 1998. Radiographic analysis and range-of-motion measurements were evaluated with an average follow-up of 65 days (range, 26-100). Preoperative criteria included < 45 degrees of dorsiflexion of the first metatarsophalangeal joint with weightbearing, no evidence of degenerative joint disease at the first metatarsocuneiform joint, and no previous surgical procedures on the first ray. The average preoperative intermetatarsal angle was 9 degrees, hallux abductus angle 17 degrees, and first metatarsal declination angle 15 degrees. The average postoperative intermetatarsal angle was 6.6 degrees, hallux abductus angle 10.3 degrees, and first metatarsal declination angle 21.7 degrees. Eighteen patients (22 feet) had a follow-up of over 6 weeks, and the first metatarsophalangeal joint was evaluated. The average gain in postoperative range of motion with weightbearing was 22.3 degrees.     

Degenerative osteoarthritis of the second metatarsophalangeal joint: second toe rigidus

Purpose

The purpose of this study was to evaluate the radiographic characteristics and structural configurations of a series of patients with a primary degenerative arthritis of the second metatarsophalangeal joint.

Methods

We studied 37 feet that had undergone surgical treatment for primary degenerative arthritis of the second metatarsophalangeal joint. The patients were compared with a randomly selected control group, without arthritis of the second metatarsophalangeal joint. The first, second, and fourth metatarsal lengths, and the size of the second metatarsal head were measured on weight-bearing anteroposterior radiographs. The patients were classified on the basis of joint-space narrowing, subchondral sclerosis, osteophyte formation, and subchondral cystic change.

Results

The average second metatarsal length was significantly longer in the study group (P = 0.01). The average length of the first metatarsal relative to the fourth metatarsal was significantly shorter (P = 0.02) in the study group, while the average length of the second metatarsal relative to the fourth metatarsal was significantly longer (P = 0.01) in the study group. The average diameter of the second metatarsal head was significantly larger in the study group (P = 0.00), and the average ratio of this diameter relative to the length of the fourth metatarsal was significantly higher in the study group (P = 0.00). A total of four feet were classified as grade 0, nine as grade 1, 17 as grade 2, and seven as grade 3.

Conclusions

Second toe rigidus should be considered as a diagnosis in patients with painful limited dorsiflexion of the second metatarsophalangeal joint without evidence of Freiberg’s infraction or trauma.     

Hemiarthroplasty augmented with bone graft for the failed hallux metatarsophalangeal Silastic implant

Symptomatic failure of Silastic^® implants at the hallux metatarsophalangeal joint can result in the challenging problem of instability which may be painful. There is often marked bone loss making reconstruction difficult. Arthrodesis sacrifices joint movement while excision arthroplasty shortens the ray and is less acceptable to active patients. We describe a case in which reconstruction was achieved by using a porous coated metatarsophalangeal hemiarthroplasty augmented with bone graft with good early results. This previously unreported technique may offer an additional surgical option for reconstruction, maintaining joint movement without compromising future arthrodesis or excision arthroplasty as salvage measures. Long term follow up is required to confirm the success of this technique.     

自体跖趾关节复合组织瓣移植修复创伤性掌指关节缺损

目的探讨自体第2跖趾关节复合组织瓣移植修复创伤性掌指关节缺损的方法和疗效。方法 2005年6月-2009年12月,对6例创伤性掌指关节缺损采用第2跖趾关节携带趾伸屈肌腱、趾固有神经及跖侧、背侧皮瓣的复合组织瓣进行修复。患者均为男性;年龄18～48岁。机器冲压伤3例,挤压伤2例,其他伤1例。第2、3、4掌指关节缺损各2例,缺损范围1.5cm×1.5cm～3.0cm×2.5cm。均伴有皮肤软组织缺损,缺损范围4cm×2cm～5cm×4cm。5例合并伸肌腱缺损,缺损长度2.5～5.0cm;3例合并屈肌腱断裂;3例合并指总神经损伤。受伤至入院时间2～6h。结果术后复合组织瓣全部成活,创面Ⅰ期愈合;供区植皮成活,切口Ⅰ期愈合。6例均获随访,随访时间1～5年。X线片示术后9～14周骨组织临床愈合良好,移植的跖趾关节与掌、指骨完全愈合。皮瓣外形不臃肿,质地柔软,痛、触觉恢复。末次随访时移植的掌指关节活动度达掌屈50～70°,背伸5～10°。按中华医学会手外科学会上肢部分功能评定试用标准,获优4例,良1例,可1例,优良率达83.3%。足部供区无明显功能障碍。结论应用自体跖趾关节复合组织瓣修复创伤性掌指关节缺损可用一个供区同时修复跖趾关节掌、背侧皮肤及骨、肌腱、神经的缺损,为复杂手外伤提供了一种有效的、可一次性修复的手术方法。     

Treatment of hallux valgus with an increased distal metatarsal articular angle: evaluation of double and triple first ray osteotomies

During a 12-year period in which 878 hallux valgus corrections were performed, 18 patients (21 feet) with symptomatic hallux valgus deformity and an increased distal metatarsal articular angle (DMAA) underwent periarticular osteotomies (double or triple first ray osteotomies). They were studied retrospectively at an average follow-up of 33 months. The surgical technique comprised a closing wedge distal first metatarsal osteotomy combined with either a proximal first metatarsal osteotomy or an opening wedge cuneiform osteotomy (double osteotomy). When a phalangeal osteotomy was added, the procedure was termed a "triple osteotomy." The average age of the patients at the time of surgery was 26 years. At final follow-up, the average hallux valgus correction measured 23 degrees and the average 1-2 intermetatarsal angle correction was 9 degrees. The DMAA averaged 23 degrees preoperatively and was corrected to an average of 9 degrees postoperatively. One patient developed a postoperative hallux varus deformity, and one patient developed a malunion, both of which required a second surgery. A hallux valgus deformity with an increased DMAA can be successfully treated with multiple first ray osteotomies that maintain articular congruity of the first metatarsophalangeal joint.     

The Effect of First Metatarsophalangeal Arthrodesis on Transverse Plane Deviation of the Second Toe: A Retrospective Radiographic Study

The purpose of this retrospective, radiographic study was to examine the effect of first metatarsophalangeal arthrodesis on the transverse plane deviation of the second metatarsophalangeal joint. Sixty-nine patients (76 feet) were separated into 3 groups based on preoperative diagnosis: group 1, hallux valgus; group 2, hallux rigidus; and group 3, rheumatoid forefoot deformity with concomitant lesser metatarsal head resection. Intermetatarsal, hallux abduction, and second metatarsophalangeal angles were measured on preoperative and follow-up anteroposterior radiographs. Multivariate analysis found a significant postoperative change (P < .001) in both the intermetatarsal and hallux abduction angles for all groups, but no significant change in the second metatarsophalangeal angle for any group. There was also no significant difference in the number of patients with medial versus lateral second toe deviation in each group. The addition of a second ray procedure, such as a digital arthrodesis or second metatarsal decompression osteotomy, in groups 1 and 2 did not correlate to the amount of change in second metatarsophalangeal deviation. However, there was a significant correlation (r = .330; P = .004) between the amount of change in the hallux abduction angle and the amount of change in the second metatarsophalangeal angle. A lack of change in the second metatarsophalangeal angle in patients with hallux valgus and hallux rigidus suggests that the creation of a stable medial buttress may protect the lesser digits. However, in patients with rheumatoid, this lack of change denotes a postoperative recurrence of lateral deviation of the second toe despite lesser metatarsal head resection and stabilization of the hallux.     

Hallux valgus: demographics, etiology, and radiographic assessment

BACKGROUND: The purpose of the study was to preoperatively evaluate the demographics, etiology, and radiographic findings associated with moderate and severe hallux valgus deformities in adult patients (over 20 years of age) treated operatively over a 33-month period in a single surgeon's practice. METHODS: Patients treated for a hallux valgus deformity between September, 1999, and May, 2002, were identified. Patients who had mild deformities (hallux valgus angle < 20 degrees), concurrent degenerative arthritis of the first metatarsophalangeal joint, inflammatory arthritis, recurrent deformities, or congruent deformities were excluded. When enrolled, all patients filled out a standardized questionnaire and had a routine examination that included standard radiographs, range of motion testing, and first ray mobility measurement. A chart review and evaluation of preoperative radiographs were completed on all eligible patients. RESULTS: One-hundred and three of 108 (96%) patients (122 feet) with a diagnosis of moderate or severe hallux valgus (hallux valgus angle of 20 degrees or more)(70) qualified for the study. The onset of the hallux valgus deformity peaked during the third decade although the distribution of occurrence was almost equal from the second through fifth decades. Twenty-eight of 122 feet (23%) developed a deformity at an age of 20 years or younger. Eighty-six (83%) of patients had a positive family history for hallux valgus deformities and 87 (84%) patients had bilateral bunions. 15% of patients in the present series had moderate or severe pes planus based on a positive Harris mat study. Only 11% (14 feet) had evidence of an Achilles or gastrocnemius tendon contracture. Radiographic analysis found that 86 of 122 feet (71%) had an oval or curved metatarsophalangeal joint. Thirty-nine feet (32%) had moderate or severe metatarsus adductus. A long first metatarsal was common in patients with hallux valgus (110 of 122 feet; 71%); the mean increased length of the first metatarsal when compared to the second was 2.4 mm. While uncommon, the incidence of an os intermetatarsum was 7% and a proximal first metatarsal facet was 7%. The mean preoperative first ray mobility as measured with Klaue's device was 7.2 mm. 16 of 22 (13%) feet were observed to have increased first ray mobility before surgery. CONCLUSIONS: The magnitude of the hallux valgus deformity was not associated with Achilles or gastrocnemius tendon tightness, increased first ray mobility, bilaterality or pes planus. Neither the magnitude of the preoperative angular deformity nor increasing age had any association with the magnitude of the first metatarsophalangeal joint range of motion. Constricting shoes and occupation were implicated by 35 (34%) patients as a cause of the bunions. A familial history of bunions, bilateral involvement, female gender, a long first metatarsal, and an oval or curved metatarsophalangeal joint articular surface were common findings. Increased first ray mobility and plantar gapping of the first metatarsocuneiform joint were more common in patients with hallux valgus than in the general population (when compared with historical controls).     

Arthrodesis of the first metatarsophalangeal joint: The “when and how”

Arthrodesis of the first metatarsophalangeal (MTP) joint has been established as the “gold standard” for the treatment of several first ray disorders, due to its perceived efficacy and the consistently reported good results in the literature. Arthrodesis is a commonly performed procedure for the treatment of end stage arthritis, rheumatoid arthritis with severe deformity, selected cases of severe hallux valgus (with or without signs of degenerative joint disease), as well as a salvage procedure after failed previous operation of the first ray. The goals of a successful 1^st MTP arthrodesis are pain alleviation and deformity correction in order to restore a comfortable gait pattern and to improve shoe wear. Several techniques have been reported with several proposals regarding the preparation of the articular surfaces and the method of definitive fixation. As with any given surgical procedure, various complications may occur after arthrodesis of the 1^st MTP joint, namely delayed union, nonunion, malunion, irritating hardware, etc.      

Freiberg's infraction of the second metatarsal head with formation of multiple loose bodies

Freiberg's infraction is an osteonecrotic disease process that most often involves the head of the second metatarsal. Establishing a diagnosis can be difficult early in the disease course, mimicking such pathologic processes as stress fracture, septic joint infection, tumors, metatarsalgia, various arthritic diseases, etc. A review of the literature reveals many treatment options and many theories of its etiology. The clinical signs and symptoms, review of the etiologies, radiographic presentation, and conservative and surgical treatments of this disease are presented. A case history and treatment summary of a patient afflicted with Freiberg's infarction involving the second metatarsophalangeal joint of the right foot is presented. Treatment consisted of evacuation of multiple loose bodies from the joint, resection arthroplasty of the diseased joint, and insertion of a total joint prosthesis.     

Motion of the first metatarsophalangeal joint

The analysis of motion of the first metatarsophalangeal joint in this study demonstrates the character of motion about this joint. Four instantaneous centers of rotation were calculated in the first metatarsal head that formed an arc encircling an area of increased stress patterns. The joint motion is made up of rolling, sliding, and compression. The fact that there is more than one center of motion contradicts the theory of a simple hinge joint. The joint is a dynamic acetabulum or "hammock," as described by Kelikian. That is, the first metatarsal head moves within a stable support comprised of the base of the proximal phalanx, the sesamoids, soft tissue, and muscle tendons. The nature of first metatarsophalangeal joint motion must be considered when contemplating surgical procedures of the first metatarsophalangeal joint.     

Low-profile Titanium Plate Construct for Early Weightbearing with First Metatarsophalangeal Joint Arthrodesis

First metatarsophalangeal joint arthrodesis is a useful procedure for various first ray pathologic entities. Multiple constructs for fixation have provided successful fusion. A retrospective study of 21 feet (18 patients) was performed after first metatarsophalangeal joint fusion using crossed Kirschner wires or compression fixation with cannulated screws followed by the application of a 2-hole low-profile partially locking titanium plate. The median age was 59 (range 41 to 76) years, and we had 4 smokers and 3 patients with diabetes in our series. Postoperatively, a compression dressing with a posterior splint was applied. The patients then transitioned to a controlled ankle motion walker, and all patients reported full weightbearing by 2 weeks postoperatively. The mean follow-up duration was 11.43 (range 6 to 27) months. The overall primary fusion rate was 95.24% (20 of 21). Two nonunions occurred; one was asymptomatic and successfully consolidated at 12 months. The second nonunion required revisional surgery with an autogenous bone graft to heal successfully. This patient was noncompliant with the postoperative regimen and had a 48-pack year history of tobacco usage. Our results have shown early weightbearing after first metatarsophalangeal joint arthrodesis can be successfully initiated with splintage or lag screw fixation and a 2-hole, low-profile, partially locking titanium plate.     

Metatarsophalangeal Joint Instability of the Lesser Toes

Metatarsophalangeal joint instability of the lesser toes is a common finding and a common cause of metatarsalgia. The clinical presentation can include swelling without digital deformity; however, often, this can progress to the development of coronal and transverse plane malalignment. In some cases, frank metatarsophalangeal joint dislocation can develop. The treatment regimen has historically focused on indirect surgical realignment using soft tissue release, soft tissue reefing, tendon transfers, and periarticular osteotomies. An improved understanding of the plantar plate has recently led to the development of a clinical staging system and surgical grading system of plantar plate attenuation. A dorsal surgical approach, using a Weil osteotomy, allows the surgeon to directly access and repair or advance the plantar plate to the base of the proximal phalanx. The addition of direct plantar plate repair could be a significant advancement in the reconstruction and realignment of metatarsophalangeal joint instability.     

第一跖趾关节痛风石的手术治疗

目的探讨和总结跖趾关节巨大痛风石的治疗方法、疗效分析。方法对12例第一跖趾关节巨大痛风石患者,在综合治疗基础上,行手术治疗,术后长期监控血尿酸。结果本组12例,全部得到随访,随访时间6～24个月,平均13．4个月。关节切口Ⅰ期愈合,仅1例切口出现延迟愈合,占8．3％。术后跖趾关节外观和关节功能满意。结论积极的手术治疗是治疗第一跖趾关节巨大痛风石的有效方法,能减少痛风急性发作的次数,改善足的外观、保护足的功能。