scholarly journals Structures at Risk with Plantar Approach Retrograde First Metatarsal Charcot Beam Screw Insertion

2017 ◽  
Vol 2 (3) ◽  
pp. 2473011417S0002
Author(s):  
David Larson ◽  
Christopher Reb ◽  
Christopher Hyer ◽  
Patrick Bull ◽  
Jeffrey Weber
Keyword(s):  
Metatarsophalangeal Joint ◽  
Metatarsal Head ◽  
Intramedullary Fixation ◽  
Easy Access ◽  
Low Grade ◽  
High Grade ◽  
First Metatarsophalangeal Joint ◽  
First Metatarsal ◽  
Plantar Plate ◽  
The Wire

Category: Diabetes, Midfoot/Forefoot Introduction/Purpose: The plantar approach for medial column retrograde intramedullary fixation of Charcot midfoot deformity allows for easy access to the ideal starting point on the metatarsal head and is supported by good clinical outcomes data. The primary argument against this approach is iatrogenic damage to the plantar structures of the metatarsophalangeal joint (MTP), which could cause tendon imbalances resulting in hallux malleus deformity. However, thus far, such complications have rarely been reported. Based on available literature, it is unclear what types of plantar structure injury occur and at what frequency. The purpose of this study was to describe plantar first metatarsophalangeal joint structure damage caused by plantar approach retrograde intramedullary medial column beam fixation. Methods: This was an IRB-exempt study. For each of 10 human cadaveric specimens, a 6.5 mm cannulated screw system was used for plantar approach retrograde medial column intramedullary fixation. This entailed using fluoroscopy to percutaneously localize a 2.8-millimeter (mm) guide wire to the center-center position on the first metatarsal head and then advanced it into the center of the medial cuneiform. A small sagittal plane skin incision was made around the wire and subcuticular tissue was bluntly divided. Next, a 4.8-mm cannulated drill was passed through a drill sleeve over the wire. Then, a countersink was used without a tissue protector. Finally, the 6.5-mm screw was inserted until it was recessed beneath subchondral bone. The specimens were then dissected to evaluate damage to the plantar structures of the 1st MTP joint. Damage to named structures was categorized as none, less than 50%, greater than 50%, and 100%. Results: The plantar plate was less than 50% damaged in all specimens. The flexor hallucis longus (FHL) tendon had less than 50% damage in 8 specimens. In one of two specimens with greater than 50% FHL damage, the torn portion of the tendon was tenodesed to the first metatarsal head by the screw (Figure). Although the medial flexor hallucis brevis (FHB) tendon was less than 50% damaged in 3 specimens and undamaged in the remainder, the medial sesamoid was less than 50% damaged in 8 specimens. In contrast, less than 50% damage occurred to the lateral FHB and lateral sesamoid in only 2 and 3 specimens, respectively. Additionally, some erosion of the plantar base of the proximal phalanx was observed in one specimen. Conclusion: The plantar structures of the hallux MTP are a tightly constrained system, which are violated during plantar approach retrograde intramedullary medial column fixation. No structures were completely transected and high-grade damage (greater than 50%) was infrequent, occurring in only two FHL tendons. Low-grade damage (less than 50%) was frequently observed to involved the FHL, medial sesamoid, and plantar plate. Based on the current findings, an FHL splitting or preserving approach is advisable to avoid high-grade damage if plantar approach is desired. A dorsal arthrotomy approach avoiding plantar structures may also be considered.

Positive Drawer Test Combined With Radiographic Deviation of the Third Metatarsophalangeal Joint Suggests High Grade Tear of the Second Metatarsophalangeal Joint Plantar Plate

2014 ◽  
Vol 7 (6) ◽  
pp. 466-470 ◽  
Author(s):  
Erin E. Klein ◽  
Lowell Weil ◽  
Lowell Scott Weil ◽  
Michael Bowen ◽  
Adam E. Fleischer
Keyword(s):  
Metatarsophalangeal Joint ◽  
Low Grade ◽  
High Grade ◽  
Deviation Angle ◽  
Duration Of Symptoms ◽  
Radiographic Findings ◽  
The Third ◽  
Plantar Plate ◽  
Radiographic Measurements ◽  
Plain Films

There is uncertainty regarding the most accurate and cost-effective method for diagnosing plantar plate injuries within the foot. The purpose of this study was to examine the combined value of using clinical and radiographic findings to diagnose high grade tears (> 50% disruption) within the second metatarsophalangeal (MTP) joint. Ninety-eight consecutive patients (117 feet) who underwent corrective surgery for plantar forefoot pain at a single foot and ankle specialty clinic were included in this retrospective analysis. All patients received a structured intraoperative assessment of the second MTP joint plantar plate by a single trained observer. Twenty-five clinical and plain film radiographic variables obtained prior to surgery were tested for their association with a high grade plantar plate tear using multiple logistic regression techniques. A positive drawer sign was the most informative individual test for differentiating high from low grade tears (odds ratio [OR] = 2.9; 95% confidence interval [CI], 0.92-9.5; sensitivity 91.5%; specificity 22%). Patients with longstanding forefoot symptoms (> 2 years) tended to be more likely to have low grade tears only (OR = 2.1; 95% CI, 0.98-4.5; sensitivity 61.7%; specificity 58.1%). Most radiographic measurements did little to distinguish high from low grade tears; however, the addition of ipsilateral third MTP joint transverse deviation angle showed a trend toward improving upon the diagnostic accuracy of strategies that used clinical findings alone (area under the curve [AUC] improved from 0.63 to 0.67; P = .11). A third MTP joint deviation angle greater than 15° in either direction combined with drawer testing and duration of symptoms achieved the highest specificities of any combination of variables examined in the study (specificities 82.4% [95% CI, 73.7%-91.1%] and 89.1 [95% CI, 82.1-96.3], respectively). The combination of a positive drawer test coupled with transverse deviation of the third MTP joint (> 15°) on plain films strongly suggests an underlying high grade plantar plate tear of the second MTP joint. However, this study highlights the need for using advanced imaging to distinguish between high and low grade tears in many instances (eg, positive drawer test and normal or near-normal alignment of the third MTP joint).Level of Evidence: Diagnostic, Level II

Clinical, Quantitative Assessment of First Tarsometatarsal Mobility in the Sagittal Plane and Its Relation to Hallux Valgus Deformity

1994 ◽  
Vol 15 (1) ◽  
pp. 9-13 ◽  
Author(s):  
Kaj Klaue ◽  
Sigvard T. Hansen ◽  
Alain C. Masquelet
Keyword(s):  
Hallux Valgus ◽  
Sagittal Plane ◽  
Metatarsophalangeal Joint ◽  
Metatarsal Head ◽  
Valgus Deformity ◽  
Main Concern ◽  
First Metatarsophalangeal Joint ◽  
First Metatarsal ◽  
Hallux Valgus Deformity ◽  
First Ray

Today, bunion surgery is still controversial. Considering that a bunion deformity in fact may be a result of multiple causes, the rationale of the currently applied techniques of surgical treatment has not been conclusively demonstrated. In view of the known hypermobility syndrome of the first ray that results in insufficient weightbearing beneath the first metatarsal head, the relationship between this syndrome and hallux valgus deformity has been investigated. The results suggest a direct relationship between painful hallux valgus deformity and hypermobility in extension of the first tarsometatarsal joint. A pathological mechanism of symptomatic hallux valgus is proposed that relates this pathology with primary weightbearing disturbances in the forefoot where angulation of the first metatarsophalangeal joint is one of the consequences. The alignment of the metatarsal heads within the sagittal plane seems to be a main concern in many hallux valgus deformities. As a consequence, treatment includes reestablishing stable sagittal alignment in addition to the horizontal reposition of the metatarsal over the sesamoid complex. As an example, first tarsometatarsal reorientation arthrodesis regulates the elasticity of the multiarticular first ray within the sagittal plane and may be the treatment of choice in many hallux valgus deformities.

Irreducible Metatarsophalangeal Joint Dislocation of the Lesser Toes

2013 ◽  
Vol 103 (3) ◽  
pp. 236-240
Author(s):  
Honlok Lo ◽  
Ping-Cheng Liu ◽  
Po-Chih Shen ◽  
Shen-Kai Chen ◽  
Yuh-Min Cheng ◽  
...  
Keyword(s):  
Kirschner Wire ◽  
Metatarsophalangeal Joint ◽  
Recurrent Dislocation ◽  
Metatarsal Head ◽  
Activity Level ◽  
Rare Injury ◽  
First Metatarsophalangeal Joint ◽  
Joint Dislocation ◽  
Plantar Plate ◽  
Metatarsophalangeal Joints

Irreducible metatarsophalangeal joint dislocation of the lesser toes is a rare injury. We present a 37-year-old man who was injured in a motorcycle accident and dislocated the first to third metatarsophalangeal joints and fractured the fourth metatarsal head. The left first metatarsophalangeal joint was reduced successfully through the closed method, but multiple attempts at closed reduction under local anesthesia failed to reduce the dislocated second and third metatarsophalangeal joints. We performed a dorsal incision between the second and third metatarsals, and the metatarsal heads were found to be entrapped under the plantar plate. Dislocation reduction was performed without damage to the plantar plate, and one Kirschner wire was used to fix the fourth metatarsal head fracture. The pin was removed 8 weeks after surgery, and the patient regained normal gait and returned to work and his previous physical activity level without recurrent dislocation. (J Am Podiatr Med Assoc 103(3): 236–240, 2013)

scholarly journals Effectiveness of the Plantar Aponeurosis Release for Limitation of the First Metatarsophalangeal Joint Extension after Hallux Valgus Surgery

2017 ◽  
Vol 2 (3) ◽  
pp. 2473011417S0001
Author(s):  
Hongjoon Choi ◽  
Daewook Kim ◽  
Yeong Hun Kang ◽  
Jong Ho Park
Keyword(s):  
Hallux Valgus ◽  
Metatarsophalangeal Joint ◽  
Metatarsal Head ◽  
Knee Extension ◽  
First Metatarsophalangeal Joint ◽  
Plantar Aponeurosis ◽  
First Metatarsal ◽  
Metatarsal Angle ◽  
Additional Procedure ◽  
The Mean

Category: Midfoot/Forefoot Introduction/Purpose: Even though stiffness of the first metatarsophalangeal joint (1MTP) is not a common complication, reduced dorsiflexion range of motion at the 1MTP after surgery for hallux valgus was reported as a complication. However, few clinical studies have investigated this issue and no clinical resolution has been reached thus far. We hypothesized that tightness of the gastrocnemius-plantar aponeurosis complex is one of the factors that limits the extension of 1MTP after hallux valgus surgery. Thus, an additional procedure of the plantar aponeurosis release during hallux valgus surgery may improve the range of extension at 1MTP. The purpose of this study was to test the efficacy of plantar aponeurosis release in improving the range of extension when a limitation is detected after hallux valgus surgery. Methods: Thirteen patients (17 feet) with limited 1MTP extension after hallux valgus surgery, underwent an additional procedure of plantar aponeurosis release. The inclusion criterion was limitation of 1MTP extension showed more than 15 degrees difference between knee extension and flexion position, measured after completing all procedures of the hallux valgus surgery. The passive range of 1MTP extension was evaluated by a goniometer while the first metatarsal head was supported with a palm, assuming a weightbearing position with knee extension and flexion, after completing all procedures of the hallux valgus surgery (Barouk test). A silfverskiold test was performed in all cases preoperatively. The weightbearing dorsoplantar and lateral radiographs of the foot were performed to measure the hallux valgus angle, intermetatarsal angle, distal metatarsal articular angle, and the talo-first metatarsal angle. Results: The mean range of 1MTP extension significantly improved from 2.53 degrees to 40.88 degrees in the knee extension position (p<0.0000). The mean range of the 1MTP extension also improved from 18.24 degrees to 43.24 degrees in the knee flexion position. The silfverskiold test was positive in 12 cases. In all patients, congruence of 1MTP was corrected. There were no surgery-related complications such as plantar aponeurosis rupture or nerve injury. Conclusion: Our study supports tightness of the gastrocnemius-plantar aponeurosis complex is one of the factors that limit the extension of 1MTP after hallux valgus surgery. Hence, plantar aponeurosis release can be considered as an effective additional procedure to improve the range of 1MTP extension when a limitation is presented after hallux valgus surgery.

The Plantar Plate of the First Metatarsophalangeal Joint

2014 ◽  
Vol 7 (2) ◽  
pp. 108-112 ◽  
Author(s):  
Douglas E. Lucas ◽  
Terrence Philbin ◽  
Safet Hatic
Keyword(s):  
Sagittal Plane ◽  
Average Distance ◽  
Proximal Phalanx ◽  
Metatarsophalangeal Joint ◽  
Metatarsal Head ◽  
Cadaver Study ◽  
Joint Line ◽  
Level Of Evidence ◽  
First Metatarsophalangeal Joint ◽  
Plantar Plate

The plantar plate of the first metatarsophalangeal (MP) joint is a critical structure of the forefoot that has been identified as a major stabilizer within the capsuloligamentous complex. Many studies have clarified and documented the anatomy of the lesser toe MP plantar plates, but few have looked closely at the anatomy of the first MP joint. Ten cadaveric specimens were examined to identify and document the objective anatomic relationship of the plantar plate, tibial sesamoid, and surrounding osseus structures. The average distance of the plantar plate distal insertion from the joint line into the proximal phalanx was 0.33 mm. The plantar plate was inserted into the metatarsal head on average 17.29 mm proximal from the joint line. The proximal aspect of the sesamoid was 18.55 mm proximal to the distal attachment of the plantar plate to the phalanx. The distal aspect of the sesamoid averaged 4.69 mm away from the distal attachment into the proximal phalanx. The footprint of the distal plate insertion was on average 6.33 mm in length in the sagittal plane. The authors hope that these objective data measures can aid in the understanding and subsequent surgical repair of this important forefoot structure. Level of Evidence: Level V: Cadaver study

Integrity of the First Metatarsophalangeal Joint: A Biomechanical Analysis

1995 ◽  
Vol 16 (6) ◽  
pp. 357-362 ◽  
Author(s):  
David Prieskorn ◽  
Stan Graves ◽  
Michael Yen ◽  
Ray John ◽  
Schultz Randy
Keyword(s):  
Soft Tissues ◽  
Metatarsophalangeal Joint ◽  
Metatarsal Head ◽  
Biomechanical Analysis ◽  
First Metatarsophalangeal Joint ◽  
Plantar Plate ◽  
Significant Damage ◽  
Different Types ◽  
Fresh Frozen

Five fresh-frozen cadaver feet obtained from traumatic amputations were tested during hyperdorsiflexion stress of the first metatarsophalangeal joint. Three different types of injury were observed: (1) rupture of the capsule proximal to the sesamoids, (2) rupture of the plantar plate distal to the sesamoids, and (3) rupture of the capsular structures medially, allowing a lateral swing of the sesamoids around the metatarsal head. Incomplete dislocation can be associated with significant damage to the plantar plate and other soft tissues of the foot.

Salvage of Failed First Metatarsophalangeal Joint Implant Arthroplasty by Implant Removal and Synovectomy: Clinical and Biomechanical Evaluation

Foot & Ankle ◽  
1992 ◽  
Vol 13 (5) ◽  
pp. 243-250 ◽  
Author(s):  
Harold B. Kitaoka ◽  
Allan D. Holiday ◽  
Edmund Y. S. Chao ◽  
Thomas D. Cahalan
Keyword(s):  
Force Plate ◽  
Metatarsophalangeal Joint ◽  
Metatarsal Head ◽  
Clinical Results ◽  
Implant Removal ◽  
Dynamic Force ◽  
First Metatarsophalangeal Joint ◽  
First Metatarsal ◽  
Joint Implant ◽  
Biomechanical Evaluation

Implant removal and synovectomy were used to treat the failure of 14 first metatarsophalangeal joint implant arthroplasties. Revision surgery was performed at an average of 3.1 years after arthroplasty. Follow-up (average 4.9 years) was possible in 10 patients, and clinical results were excellent in seven patients, good in one patient, fair in one patient, and poor in one patient. No significant changes in alignment occurred, although a trend toward toe extension was noted. Dynamic force plate studies in these patients demonstrated less pressure under the first metatarsal head and greater loading under the lateral forefoot. The great toe had less contact time during gait in the involved feet than in the control feet.

Cryptococcal Osteomyelitis of the First Metatarsal Head in an Immunocompetent Patient

2017 ◽  
Vol 107 (3) ◽  
pp. 248-252
Author(s):  
Jae Hoon Ahn ◽  
ChanJoo Park ◽  
Choong Woo Lee ◽  
Yoon-Chung Kim
Keyword(s):  
Fungal Infections ◽  
Full Range ◽  
Metatarsophalangeal Joint ◽  
Metatarsal Head ◽  
Immunocompetent Patient ◽  
First Metatarsophalangeal Joint ◽  
Osteolytic Lesions ◽  
First Metatarsal ◽  
Fungal Osteomyelitis

Most fungal infections primarily occur in immunocompromised patients. We describe a case of osteomyelitis involving the first metatarsal head due to Cryptococcus neoformans in a previously healthy immunocompetent patient. She was treated with surgical debridement combined with antifungal drug therapy for 6 months. At 5-year follow-up, she remained symptom free with full range of motion of the first metatarsophalangeal joint. Fungal osteomyelitis should be considered as a possible cause in osteolytic lesions in the metatarsal bone.

Medial Deviation of the First Metatarsal Head as a Result of Flexion Forces in Hallux Valgus

Foot & Ankle ◽  
1992 ◽  
Vol 13 (9) ◽  
pp. 515-522 ◽  
Author(s):  
Antal Petrus Sanders ◽  
Christiaan Johannes Snijders ◽  
Bert van Linge
Keyword(s):  
Hallux Valgus ◽  
Statistical Significance ◽  
Metatarsophalangeal Joint ◽  
Metatarsal Head ◽  
First Metatarsophalangeal Joint ◽  
First Metatarsal ◽  
Valgus Angle ◽  
Flexor Muscles ◽  
Muscle Balance ◽  
Flexion Force

Several questions with regard to the hallux valgus complex, which includes metatarsus primus varus, give rise to discussion. How do bunions develop? Is disturbed muscle balance at the first metatarsophalangeal joint important in the pathogenesis of the hallux valgus complex? What is the relation between dynamic plantar load distribution and pain in the ball of the foot? What is the cause of recurrences of deformity after surgery? To answer these questions, we started with the bio-mechanical model of Snijders et al., 31 which states that contraction of flexor muscles of the hallux worsens its valgus angle and causes medial deviation of the first metatarsal head. The present study was designed to validate the model on patients. When pressing the hallux downward, simultaneously the force under the toe and the medial deviation of the first metatarsal head were measured on preoperative patients and on controls (35 subjects in all). We could demonstrate with statistical significance that (1) when the subjects with hallux valgus push the great toe on the ground, the first metatarsal head moved in medial direction; in other words the foot widened. In the controls, as an average, the foot became narrower. (2) The greater the valgus deviation of the hallux, the greater the effect of the toe flexors, and (3) the greater the valgus deviation of the hallux, the less maximal flexion force it can apply. Implications of these findings on conservative and surgical therapy are discussed. The recurrences of deformity after first metatarsal osteotomies are explained by the action of the hallux flexors. The stable result of arthrodesis of the first metatarsophalangeal joint is expected to be accompanied by narrowing of the foot as a result of contraction of the flexor muscles.

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