Foot & Ankle International

The pathomechanics for the development of the hallux valgus deformity takes place at the first metatarsophalangeal joint-the sesamoid complex. The sesamoid complex consists of seven muscles, eight ligaments, and two sesamoid bones. When the first metatarsal escapes the complex and drifts medially, the sesamoids remain twisted in situ, several of the ligaments “fail,” and others contract. The authors propose reduction of the metatarsus primus varus by first metatarsal osteotomy and appropriate ligament releases and plications to restore alignment. A detailed understanding of the pathomechanics is essential for proper interpretation of the problems and anticipated lasting surgeries.

A retrospective study of 15 Mitchell and 15 Chevron osteotomies was undertaken in order to compare the efficacy of these two procedures in the correction of hallux valgus. Patient satisfaction, clinical findings, and roentgenographic measurements were all carefully evaluated after follow-up periods of 21 ± 5 months for the Chevron and 34 ± 8 months for the Mitchell procedures. Differences observed were a better correction of the angle between the first and second metatarsals by the Mitchell osteotomy (2.3 vs 5.5 degrees) and a tendency to loose the correction in the immediate postoperative period for the Chevron osteotomy. However, no clinical superiority could be demonstrated, nor did patient satisfaction differ in the two techniques. The authors conclude that these procedures give essentially equivalent results. Although the outcome was generally considered satisfactory by the patient, nearly 40% of both groups had metatarsalgia in the lateral rays, which stresses the importance of carefully considering load distribution across the foot in planning any corrective surgery.>

The reliability and effectiveness of the treatment of hallux rigidus and sympomatic arthritis of the first metatarsophalangeal joint by the technique of cone arthrodesis are discussed. The authors reviewed the long-term results of cone arthrodesis in 51 patients with 60 operated feet. The average age was 55 years (range, 28 to 75 years) and the average length of follow-up was 39 months (range, 1 to 12 years). On questioning the patients regarding function, cosmesis, and pain, 41 of 51 patients were happy, eight of 51 patients were satisfied, and two of 51 were unhappy with their feet. No patient complained of persistent or recurrent hallux valgus deformity. Radiologically and clinically 58 of 60 first metatarsophalangeal joints were solidly fused. Two patients had a fibrous ankylosis which was functional and painless. Function with respect to gait and ability to walk on tiptoe and run was normal in all patients. In summary, the authors feel that this procedure is a reliable, effective treatment of painful arthritis of this joint.

This report describes the use of a double-stemmed flexible hinge silicone elastomer implant for use as a total joint replacement for the metatarsophalangeal joint of the great toe. Experience with this prosthesis has been since 1971 with 103 prostheses implanted in 71 patients with a minimum follow-up of 12 months and an average follow-up of 7.4 years. Of the 71 patients, 40 had osteoarthritis with 64 joints replaced, 22 had rheumatoid arthritis with 29 joints replaced, four patients were revised from a failed excisional hemiarthroplasty, three patients with four joints involved were revised from a failed silicone implant hemiarthroplasty, and two patients had a surgically arthrodesed metatarsophalangeal joint taken down and revised to a total joint arthroplasty. Of the total number of patients involved, eight were men, 63 were women, and the average age per joint was 56 years.

The results were graded as excellent, good, fair, and poor on two bases: relief of pain and the cosmetic result. Overall results were good. On the basis of these results over a 12-year period, it was concluded that there is a place for total joint prosthetic replacement in the surgical reconstruction of the painful, destroyed metatarsophalangeal joint of the great toe.

Seven cases of painful reactive synovitis following great toe Silastic hemiarthroplasty have been observed. All cases were treated successfully with synovectomy and removal of the implant. Microscopic examination of the synovium uniformly demonstrated a chronic foreign-body giant-cell reaction with intracellular and extracellular silicone elastomer particles. Gross examination of the implants showed varying degrees of erosion of the articulating surface. Abrasion of a Silastic implant creates tree-floating silicone elastomer particles that can precipitate a reactive synovitis. The authors believe an irregular, degenerated first metatarsal head is a contraindication to an interpositional Silastic hemiarthroplasty.

Crippling equinocavovarus position of the foot in advanced Charcot-Marie-Tooth disease with its attendant metatarsalgia tender calluses and rigidity creates painful, limited, hobbling ambulation with lowered work and general activity tolerance. The object of the surgeries is to convert this foot into a plantigrade, more flexible, painless unit. Surgery consists of plantar fasciotomies off the tubercle of the os caleis and also transversely through the middle of the longitudinal arch. Dorsally angulated green-stick osteotomies are performed at the bases of all the metatarsals. A Jones operation with transfer of the long extensor great toe tendon through the neck and head of the first metatarsal and arthrodesis of the IP joint of the great toe complete the surgery. Often it is necessary to do Bunnell repair lengthening of the flexor hallucis longus tendon. Occasionally, the first metatarsophalangeal joint needs dorsal capsulotomy and lengthening of the short extensor tendon. Variations in and simplicity of techniques are demonstrated with a case report. Ten patients (eight men and two women: 18 feet), ranging in age from 18 to 46 years (average age, 29 years), with a 3- to 6-year follow-up are herein reported. Correction has been maintained in the oldest case.

Five patients with symptomatic flexible pes planus unresponsive to conservative therapy underwent nine open wedge anterior calcaneal osteotomies and advancement of the posterior tibial tendon. The average follow-up was 6 years, 8 months. Three patients exhibited medial and plantar talonavicular subluxation and naviculocuneiform sag. There were three excellent results, three very good, two good, and one poor. The patient with a poor rating was asymptomatic, had normal foot motion, and was satisfied with the procedure.