A new bone-ligament-bone autograft from the plantar plates of the toes and its potential use in scapholunate reconstruction: an anatomical study

The study was performed to investigate a new bone-ligament-bone autograft from the plantar plate of the toes. The anatomic properties of the plantar ligaments and the technical feasibility to harvest a bone-ligament-bone graft were examined to evaluate the potential use of this graft for a suitable reconstruction of the scapholunate (SL) interosseous ligament. The plantar plate of the metatarsophalangeal joints of the second to fifth toe and the proximal interphalangeal joints of the second to fourth toe were examined in 20 cadaver feet (15 fresh and 5 embalmed cadavers) and measurements such as length, thickness, and width were taken. The average length of the plantar ligaments of the proximal interphalangeal joint was 0.63 cm (D3) and 0.62 cm (D4). The length of the plantar plates of the proximal interphalangeal joint of the third and fourth toe was found to be similar to that of the SL ligament. In addition to the measurements, a bone-ligament-bone autograft of the plantar plates of the metatarsophalangeal joint was designed as an SL-ligament substitute and successfully transplanted into cadaveric wrists. This new autograft is intercalated between the scaphoid and lunate and, contrary to all previous methods, not simply superimposed upon them. Length of the plantar plates was considered by the authors as the main criteria for selection of the new bone-ligament-bone graft. The plantar plate of the proximal interphalangeal joint of the third and fourth toe showed a similar length compared with the SL ligament. Therefore, it can be concluded from the data that this bone-ligament-bone graft can be a suitable replacement for the SL ligament.     

Combined Plantar Plate and Hammertoe Repair with Flexor Digitorum Longus Tendon Transfer for Chronic, Severe Sagittal Plane Instability of the Lesser Metatarsophalangeal Joints: Preliminary Observations

The plantar plate provides a substantial static support for the lesser metatarsophalangeal joints. Insufficiency involving tear, attenuation, or absence of this structure can result in significant sagittal plane instability and deformity. When a plantar plate tear is established and is unresponsive to conservative treatment, plantar plate repair is indicated to address symptoms and reestablish static joint stability. The authors hypothesized that combined plantar plate and hammertoe repair with flexor digitorum longus tendon transfer provides a viable surgical option to address chronic plantar plate tears with secondary joint instability and digital deformity. The authors retrospectively evaluated a case series of 18 consecutive patients (20 feet) who underwent this combined surgical strategy as the primary procedure to address severe, chronic sagittal plane instability of the lesser metatarsophalangeal joints. Other procedures were performed concurrently in all cases to address predisposing factors and concomitant deformities. Method of evaluation included a subjective, objective, and radiologic evaluation performed at least 1 year after their surgical procedure. Two rating systems were used: the Lesser Metatarsophalangeal-Interphalangeal Scale from the American Orthopedic Foot and Ankle Society, and another designed by the authors. The average postoperative American Orthopedic Foot and Ankle Society score was 83.2/100 and the average postoperative score with the authors' rating system was 87.7/100. All patients were satisfied with their postoperative result. Study results suggest combined plantar plate and hammertoe repair with flexor digitorum longus tendon transfer to be a viable option to address severe, chronic sagittal plane instability of the internal lesser metatarsophalangeal joints. ACFAS Level of Clinical Evidence: 4.     

Nonoperative Treatment of a Lesser Toe Plantar Plate Tear with Serial MRI Follow-up: A Case Report

With the current data concentrating on different operative treatment options for plantar plate tears, few data can be found on possible nonoperative treatment strategies for this entity and the specifics of such treatment. In the present case report, the successful nonoperative treatment of a patient with a rupture of the plantar plate in a lesser toe metatarsophalangeal joint is presented. The patient was followed up using repeat clinical examinations and high-resolution magnetic resonance imaging scans for 1 year after the imitation of therapy to provide information on the different stages of the healing process.     

Lesser Metatarsophalangeal Joint Pathology Addressed With Arthrodesis: A Case Series

Lesser metatarsophalangeal joint pathology is a common condition facing the foot and ankle surgeon, often beginning as a mild subluxation of the toe and progressing to a full dislocation of the metatarsophalangeal joint. In severe or recalcitrant deformities, traditional conservative and surgical methods can fail to resolve the issue. We report on 4 patients with 5 severely dislocated lesser metatarsophalangeal joints with varied etiologies and comorbidities who underwent arthrodesis of these joints using screw and plate fixation. All patients achieved radiographic and clinical signs of union at an average of 16.4 weeks.     

The treatment of rheumatoid foot deformities

Rheumatoid hindfoot deformity presents with hindfoot eversion, flattening of the longitudinal arch and abduction of the forefoot. Splayfoot, as the typical rheumatoid forefoot deformity, is mostly associated with various toe malformations, i.e. hallux valgus,hammer toe and claw toe,which may either be attributed to hindfoot malalignment or develop as a separate entity. The algorithm of treatment, comprising clinical assessment of both lower limbs, includes both orthotic shoe devices and surgical treatment. In rheumatoid flatfoot, arthrodesis of the hindfoot with lengthening of the lateral column and reorientation of joint congruency represent the gold standard of treatment. Despite this principle, the ankle joint should be kept mobile to facilitate standing and walking. Therefore, total ankle prosthesis is thought to be superior. Methods involving the preservation of the lesser metatarsophalangeal joints may be of benefit in providing sufficient ground contact with the toes. Nevertheless, resection arthroplasties are frequently required in cases of arthritic joint destruction. Arthrodesis of the first metatarsophalangeal joint may provide an adequate push-off for the big toe which can not be expected from resectional arthroplasties.     

The Weil osteotomy of the lesser metatarsals: a clinical and pedobarographic follow-up study

The clinical results with pedobarographic analysis were assessed in 32 patients (59 metatarsals) who underwent a distal metatarsal shortening (Weil) osteotomy for either intractable plantar keratoses or chronically dislocated lesser metatarsal phalangeal joints. All patients had increased pressure under the involved metatarsal heads. Thirty three of the 59 metatarsophalangeal (MTP) joints were chronically dislocated. At an average follow-up of 30 months, patients rated the result as excellent or good for 32 of the 37 feet (86%). The mean preoperative AOFAS score was 59 (maximum 100), which improved to 81 post-operatively. This difference is significant: p = 0.00001 (with t-test). Comparison of the pre and post-operative pedobarographic measurements showed a significant decreased load under the affected metatarsal heads (p = 0.05). A complete disappearance of the callus was noted under 44 operated metatarsals (75%) and partial disappearance under 12 metatarsals (20%). Two symptomatic transfer lesions occurred under an adjacent metatarsal head. Recurrent dislocations occurred in 5 joints (15%). While metatarsophalangeal joint range of motion was significantly diminished, toe strength was maintained. Average metatarsal shortening was 5.9 mm with no nonunions, delayed unions, or malunions. The Weil shortening osteotomy is a simple and reliable procedure which can effectively reduce the load under the lesser metatarsophalangeal joints and is helpful for the reduction of dorsally dislocated MTP joints.     

Toe flexors strength and passive extension range of motion of the first metatarsophalangeal joint in individuals with plantar fasciitis

STUDY DESIGN: Cross-sectional study. OBJECTIVE: To determine if a difference exists in toe flexors strength and passive extension range of motion of the first metatarsophalangeal joint between individuals with unilateral plantar fasciitis and control subjects. BACKGROUND: Weakness of the dynamic longitudinal arch supporters and shortening of the plantar fascia have been suggested as etiologic factors for plantar fasciitis. METHOD AND MEASURES: Twenty subjects with unilateral plantar fasciitis participated in the study. Subjects had had symptoms for an average (+/-SD) of 19.9 +/- 33.2 months prior to participating in the study. Twenty control subjects matched for sex and age were also tested. Each subject was measured bilaterally for passive extension range of motion of the first metatarsophalangeal joint and peak resistance force observed during an isometric test of toe flexors strength. RESULTS: Subjects with unilateral plantar fasciitis demonstrated weaker toe flexors (P<.05) than the control subjects. A significant main effect for feet also indicated that the toe flexors for the involved feet were significantly weaker than the uninvolved feet (P<.05) of subjects with unilateral plantar fasciitis. Passive extension range of motion of the first metatarsophalangeal joint was not significantly different between the involved and the uninvolved feet for subjects with plantar fasciitis. CONCLUSION: Results for our subjects indicate that the extensibility of soft tissues influencing extension of the first metatarsophalangeal joint was not related to the presence of plantar fasciitis. Additional research is needed to determine if toe flexors weakness is a cause or a result of plantar fasciitis and if strengthening regimes for the toe flexors are effective interventions for plantar fasciitis.     

Surgical correction of metatarsophalangeal joint dislocation and arthritic deformity: the partial head and plantar condylectomy.

The partial head and plantar condylectomy has been presented as a procedure indicated in the correction of dislocated metatarsophalangeal joints. Although there may be a number of causes of dislocation, the surgical correction is the same. A skin plasty is useful in preventing a cocked-up toe, and this is performed at the plantar aspect of the base of the toe. A V-osteotomy, or other metatarsal dorsiflectory procedure, is recommended when the neighboring metatarsal is only slightly plantar flexed or greater. This prevents the occurrence of transfer lesions so commonly associated with this procedure. Two case studies have been presented demonstrating successful results when the procedure is performed on both the second and third metatarsophalangeal joints. We contend that the partial head and plantar condylectomy is a valuable procedure in reconstructive surgery of the foot.     

Lesser toe deformities

Lesser toe deformities are caused by alterations in normal anatomy that create an imbalance between the intrinsic and extrinsic muscles. Causes include improper shoe wear, trauma, genetics, inflammatory arthritis, and neuromuscular and metabolic diseases. Typical deformities include mallet toe, hammer toe, claw toe, curly toe, and crossover toe. Abnormalities associated with the metatarsophalangeal (MTP) joints include hallux valgus of the first MTP joint and instability of the lesser MTP joints, especially the second toe. Midfoot and hindfoot deformities (eg, cavus foot, varus hindfoot, valgus hindfoot with forefoot pronation) may be present, as well. Nonsurgical management focuses on relieving pressure and correcting deformity with various appliances. Surgical management is reserved for patients who fail nonsurgical treatment. Options include soft-tissue correction (eg, tendon transfer) as well as bony procedures (eg, joint resection, fusion, metatarsal shortening), or a combination of techniques.     

Small joint arthroscopy of the foot

The arthroscopic approach to small joints of the foot has made many advances in recent years, which can be directly related to the improvement of the surgical equipment. This improvement has led to more indications for the use of arthroscopy as well as minimizing the complications. Several articles recently have presented experiences in arthroscopic surgery in the?small joints of the foot; however, its use is still relatively limited. Approaches to small joints of the foot involve the first metatarsophalangeal joint, tarsometatarsal joint, and Chopart joint, as well as the interphalangeal joint to the great toe and lesser toes.     

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.     

Arthroscopic-assisted correction of claw toe or overriding toe deformity: plantar plate tenodesis

Hyperextension of the metatarsophalangeal joint is the key component of claw toe deformity. We describe an arthroscopic technique to stabilize the plantar plate and reduce the metatarsophalangeal joint. Under arthroscopic guide, the dorsal capsule is released. The plantar plate is anchored and sutured to the extensor digiturum longus tendon. In case of overriding toe deformity, the medial capsule is also reduced and lateral capsule is plicated under arthroscopic guide     

Deformitätsassoziierte Behandlung des Hallux-valgus-Komplexes

Hallux valgus represents a combined deformity with malpositioning of the big toe in the metatarsophalangeal joint and metatarsal splaying due to metatarsus primus varus formation. It is defined on the basis of joint condition of the metatarsophalangeal and tarsometatarsal (TMT) joints, the extent and congruence or incongruence of malposition, mobility of the metatarsophalangeal joint and TMT stability. Basic resection appears to be indicated only in exceptional cases. Depending on the degree of severity, deformities can be corrected by means of distal, diaphyseal or proximal osteotomies and TMT arthrodeses. Any correction requires the use of subtle soft tissue surgery with recentering of the tendon, tightening of the medial capsule and abductor hallucis and releasing the lateral capsule. A check-list-like analysis of hallux valgus deformity helps determine the ideal procedure and avoid over- or under-treatment.     

Long term results of the Toefit-Plus replacement for first metatarsophalangeal joint arthritis

Hallux rigidus is osteoarthritis affecting the metatarsophalangeal joint of the first toe. Patients often complain of pain and stiffness with pain being aggravated by walking, particularly during toe-off in the gait cycle. Osteoarthritis of the metatarsophalangeal joint is commonly treated with arthrodesis or resection arthroplasty. Metallic replacement of this joint is used sometimes but is not widely accepted. The use of silastic joints has problems with synovitis and implant failure. The authors used titanium implants, which can be screwed into the metatarsal and phalanx, allowing good fixation without the use of bone cement. Release of the tight plantar capsule and tissues is necessary to achieve better range of movement and correct implant positioning.Fifty five cases of arthritis of the first metatarsophalangeal joint were treated surgically with Toefit-Plus™ joint replacement. The implant consists of both metatarsal and phalangal components and a fixed-bearing polyethylene insert. All patients had a release of tight soft tissues on the plantar side. Follow up occurred at 84 to 144 months after surgery (mean of 134 months), and the results showed increasing numbers of implant failures and revisions (21%) of Toefit-Plus™ implants. 47 patients were available for review. Twenty four (51%) out of 47 patients reported satisfactory results with Toefit-Plus™ arthroplasty. Ten of these patients (21%) had removal of implants and further surgical procedures were needed due to implant failure. Eleven (23%) out of 47 patients still complained of pain despite having joint replacement with the Toefit-Plus ™ implant.There is a high rate of complications with the Toefit-Plus™ implant resulting in revision surgery. Patients should have the risks associated with arthroplasty clearly explained, including the risk of revision, and the option of arthrodesis should be discussed when planning surgery. Further trials and redesign of implants may help to improve results. The authors would not recommend the Toefit-Plus™ implant due to poor results seen in one third of patients.     

Rheumatoid forefoot reconstruction. A long-term follow-up study

BACKGROUNDS: The purpose of the present study was to assess the results of reconstruction of the rheumatoid forefoot with arthrodesis of the metatarsophalangeal joint of the great toe, resection arthroplasty of the metatarsal heads of the lesser toes, and open repair of hammer-toe deformity (arthrodesis of the proximal interphalangeal joint) of the lesser toes when this deformity was present. METHODS: A retrospective study of forty-three consecutive patients (fifty-eight feet) with severe rheumatoid forefoot deformities was performed. Six patients (six feet) died before the most recent follow-up, and five patients (five feet) were excluded because a subtotal procedure had been performed. No patient was lost to follow-up. Thus, the study included thirty-two patients (forty-seven feet) in whom reconstruction of a rheumatoid forefoot had been performed by the author. RESULTS: All first metatarsophalangeal joints had successfully fused at an average of seventy-four months (range, thirty-seven to 108 months) postoperatively. The average postoperative hallux valgus angle was 20 degrees and the average postoperative angle subtended by the axes of the proximal phalanx and the metatarsal of the second ray (the MTP-2 angle) was 14 degrees, demonstrating that a stable first ray protected the lateral rays from later subluxation. One hundred and thirty-two (70 percent) of the 188 lesser metatarsophalangeal joints were dislocated preoperatively, compared with thirteen (7 percent) postoperatively. The result of the procedure (as rated subjectively by the patient) was excellent for twenty-three feet, good for twenty-two, and fair for two. There were no poor results. The average postoperative score according to the system of the American Orthopaedic Foot and Ankle Society was 69 points. Postoperative pain was rated as absent in eighteen feet, mild in twenty-five, moderate in four, and severe in none. Fifteen feet were not associated with any functional limitations, twenty-eight were associated with limitation of recreational activities, and four were associated with limitation of daily activities. At the time of the most recent follow-up, no special shoe requirements were reported. Fourteen feet (30 percent) had a reoperation for the removal of hardware from the first metatarsophalangeal joint, a procedure on the interphalangeal joint of the great toe, or additional procedures on the lesser toes or lesser metatarsophalangeal joints. CONCLUSIONS: In the present study, arthrodesis of the first metatarsophalangeal joint, resection arthroplasty of the lesser metatarsal heads, and repair of fixed hammer-toe deformities with intramedullary Kirschnerwire fixation resulted in a stable repair with a high percentage of successful results at an average of six years after the procedures.     

Operation of hammer toes and claw toes, and treatment of unfavourable results (author's transl)]

Hohmann's operation of hammer toes and claw toes will produce a poor result if there is a contracture due to hyperextension in the metatarsophalangeal joint. In such cases, preference should be given to the operation according to Taylor (resection arthrodesis of the first or, in rarer cases, of the second interphalangeal joint, dorsal incision of the capsule of the metatarsophalangeal joint, if necessary elongation of the extensor tendon, intramedually fixation by Kirschner wire). In case the operated toe points rigidly to dorsal or hangs limply as a result of Hohmann's operation, a cosmetically and functionally entirely satisfactory result can be achieved by means of operative mobilisation of this preoperated toe and by producing a cutaneously syndactylia with the next, smaller toe. - If a hammer toe is dislocated in the metatarsophalangeal joint, removing the base according to Gocht should be combined with an operative syndactylia to guide and hold the toe accurately in line with the other toes.     

Arthrodese der Mittel- und Endgelenke der Kleinzehen

Objective

Elimination of the fixed lesser toe deformity by arthrodesis of the proximal or distal interphalangeal joints (PIP and DIP, respectively).

Indications

Painful fixed deformity. PIP joint: fixed hammer toe or clawtoe. DIP joint: fixed mallet toe. Relative indication: flexible hammer toe, clawtoe or mallet toe.

Contraindications

General operative contraindications. Relative contraindications also include severe deformities affecting the metatarsophalangeal (MTP) joint, for which the arthrodesis should combine an operative procedure of the MTP joint.

Surgical techniques

PIP arthrodesis: Dorsal incision centered over the PIP joint, exposure of the PIP joint by transsecting the extensor tendon and joint capsule, release of the collateral ligaments, while carefully protecting the neurovascular bundles, resection of the head of the proximal phalanx and the articular surface of the middle phalanx. The arthrodesis should be stabilised in mild plantar flexion. The tip of the toe should have contact with the surface when the push up test is done. The arthrodesis technique depends on the implant used. The extensor tendon is sutured and the wound is closed. DIP arthrodesis: dorsal incision centered over the DIP joint, exposure of the DIP joint by transsecting the extensor tendon and joint capsule, release of the collateral ligaments, while carefully protecting the neurovascular bundles. Resection of the head of the middle phalanx and the articular surface of the distal phalanx. The arthrodesis should be stabilised in straight position. The arthrodesis technique depends on the implant used. The extensor tendon is sutured and the wound is closed.

Postoperative management

Postoperative full weight bearing for 3–6 weeks, depending on the arthrodesis technique used.

Results

Stabilisation of the toe with adequate alignment is achieved by arthrodesis of the affected joint. In general, digital fusion of the fixed lesser toe pathology shows a high subjective satisfaction rate among the patients, although the rate of pseudarthrosis in attempted PIP or DIP arthrodesis is quite high. Major reasons for postoperative dissatisfaction were swelling, wound necrosis, pin infection, floating toe, shortening and angulation of the toe.     

Ultrasound Imaging for Diagnosis of Plantar Plate Ruptures of the Lesser Metatarsophalangeal Joints: A Retrospective Case Series

Tears of the plantar plate can be a source of significant forefoot pain, leading to alterations of foot function and gait. The objective of the present retrospective study was to further determine the value of ultrasound imaging in diagnosing plantar plate tears after clinical evaluation through a comparison of the ultrasound and intraoperative examination findings. Eight patients were identified who had undergone surgical intervention for a painful lesser metatarsophalangeal joint after ultrasound examination to diagnose a plantar plate pathologic entity. The intraoperative examination findings were used to calculate the sensitivity, specificity, and positive and negative predictive values of ultrasound in the diagnosis of plantar plate tears. The sensitivity and specificity of the ultrasound examination was 1 and 0.6, respectively. The positive and negative predictive value was 0.6 and 1, respectively. An ultrasound examination in the diagnosis of lesser metatarsophalangeal joint plantar plate tears displayed comparable sensitivity in identifying the pathologic features when compared with magnetic resonance imaging, with considerably less financial cost for the examination.     

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.     

Lesser metatarsophalangeal joints: intra-articular distension, volumetric measurements, and changes of position

Plantarflexion of the second metatarsophalangeal (MTP) joint with intra-articular injection has previously been observed and commented upon, and the purpose of this study was to determine motion of the lesser toes with direct fluid infusion into the lesser MTP joints. Fluid distension was found to cause variable postural changes in all lesser toes; the most consistent change was plantarflexion of the second metatarsophalangeal joint. Dorsiflexion of the third, fourth, and fifth MTP joints was observed, but less reliable than plantarflexion of the second MTP joint. The average volume in each of the lesser MTP joints was less than 1 cc. Plantarflexion of the second MTP joint was usually, but not always, indicative of intra-articular distention. Aspiration of these joints (given their small volume capacity) may not be a reliable or therapeutically useful technique.