What is new about hallux rigidus?

Hallux rigidus (HR) represents one of the most frequent forefoot disorders, together with hallux valgus and lateral toe deformities, being the most frequent degenerative process in the foot and ankle.This publication is the result of the collaboration of colleagues of the Spanish Society of Medicine and Foot and Ankle Surgery (Sociedad Española de Medicina y Cirugía del Pie y Tobillo, SEMCPT) and the Argentinean Society of Medicine and Foot and Leg Surgery (Sociedad Argentina de Medicina y Cirugía de Pie y Pierna, SAMCPP). It is an honor for us to have this work edited in the Journal of the Foot & Ankle, a journal with a marked Latin identity. We really thank Alexandre Leme Godoy-Santos, Chairman of the Editorial Board, for his help and contribution. This update topic has been coordinated by R. Viladot Pericé and A. Viladot Voegeli, together with M. Herrera and M. Núñez-Samper.Considering the interest and the extent of this topic and, according to the coordinators, we have divided the publication into two parts. The first one describes general aspects (definition, etiology, classification, treatment algorithm, etc.) and the conservative treatment of HR, whereas the second one addresses the different surgical techniques described to treat this disease.The aim of this work is to review our knowledge on HR and to perform an update on the innovations that have emerged during the last years.

Effect of gait protocols and postoperative shoes on off-loading of forefoot in preoperative patients for forefoot disorders

ABSTRACT Objectives The purpose of this study was to clarify the effect of gait protocols and postoperative shoes on forefoot load in preoperative patients for forefoot disorders and compare footwear comfort between different types of postoperative shoes. Methods Fourteen subjects scheduled to undergo forefoot surgeries were recruited. The maximum force under the forefoot region was measured during 10 m straight walking in two gait patterns with six different shoe types. Visual analogue scale (VAS) scores for footwear comfort, subjective lower thigh pain, and electrical activities of lower thigh muscles were also evaluated. Results The body weight-normalized maximum force under the forefoot region significantly decreased in step-to gait compared to normal gait regardless of the shoe types used. Under the same gait condition, no significant difference was observed in the forefoot off-loading effect between the different shoe types used. Significantly worse VAS scores, significantly higher tibialis anterior muscle activities, and complaints of lower thigh pain were demonstrated in the gait with the reverse camber shoe. Conclusions Gait protocol of step-to gait had more forefoot off-loading effect than postoperative shoes. The forefoot off-loading effect did not differ among the postoperative shoes, suggesting that postoperative shoes can be selected with an emphasis on footwear comfort.

Forefoot Pain in the Lesser Toes: Anatomical Considerations and Magnetic Resonance Imaging Findings

Various conditions may result in forefoot pain. Magnetic resonance (MR) imaging allows accurate assessment of many of these conditions. We provide an overview of forefoot disorders divided into bones, capsule and plantar plate, musculotendinous structures, neurovascular structures, and subcutaneous tissue. We review normal anatomical features as well as MR imaging findings of common disorders.

Open vs Arthroscopic First Metatarsophalangeal (MTP) Joint Fusion

Category: Arthroscopy, Basic Sciences/Biologics, Midfoot/Forefoot Introduction/Purpose: First metatarsophalangeal (MTP) joint fusion has been proven to be an effective treatment for a variety of conditions such as osteoarthritis, rheumatoid arthritis, hallux rigidus/valgus, and failed first MTP arthroplasties. Multiple surgical techniques have been described in the literature with regards to bone preparation and different fixation with varying degrees of success. Studies have demonstrated that one of the complications of MTP fusion is first ray shortening, which can lead to symptomatic forefoot disorders such as transfer metatarsalgia of the lesser toes. Patients can develop altered gait mechanics that manifest as decreased ankle plantarflexion at toe-off and decreased step gait. The purpose of this study was to compare the amount of first ray shortening that occurs during MTP fusions with open versus arthroscopic technique. Methods: Ten specimens were divided into two groups. Group one was arthroscopic and group two was open technique. For arthroscopy, the long extensor (EHL) tendon and first MTP joint were identified. Dorsomedial and dorsolateral ports were created at the level of the MTP joint. A small curette was used to prepare the joint. For open technique, an incision was made on the dorsum of the first MTP joint and carried down to the subcutaneous tissue. The EHL tendon was dissected and a capsulotomy was performed. The head of the first metatarsal and the base of the proximal phalanx were exposed. Dome-shaped reamers were used to prepare the joint. A lag screw was used for fixation. AP and lateral radiographs were obtained. The length of the first ray was measured from the base of the first metatarsal to the distal end of the proximal phalanx. Pre and post fixation lengths were compared. Results: A comparison of pre and post fixation first ray length demonstrated that there was an average decrease of 2.2 mm in the arthroscopic group and 2.1 mm in the open technique group. Even though both techniques shortened the average length of the first ray, there was no statistically significant difference between the groups (p = 0.934). Comparison of the average percentage of surface area prepared of the head of the first metatarsal showed a statistically significant difference (p = 0.035) between both techniques. In contrast, comparison of the average percentage of surface area prepared of the base of the proximal phalanx and total surface area prepared did not show a statistically significant difference (p = 0.159 and p = 0.051) between the groups. Conclusion: First metatarsophalangeal (MTP) joint fusion has been proven to be an effective treatment for a variety of conditions that affect the first ray. First ray shortening can lead to symptomatic forefoot disorders and altered gait patterns. The results of our study indicate that there is no statistically significant difference in first ray length after MTP fusion performed by either arthroscopic or open technique. Our study also showed that even though the average percentage of surface area prepared of the head of the first metatarsal was statistically different between both groups the average percentage of total surface area prepared was not.

Forefoot Reconstruction Following Metatarsal Head Resection Arthroplasty With a Plantar Approach—A 20-Year Follow-Up

Background: Rheumatoid arthritis (RA) can cause significant forefoot disorders. If forefoot deformity and pain are severe, surgical treatment can be considered. The aim of this study was to analyze the long-term outcomes of surgical forefoot correction per Tillmann, which involves resection of the metatarsal heads through a transverse plantar approach for the lesser toes and a dorsomedial approach to the great toe. Methods: This retrospective study used patient-based questionnaires to analyze the revision rate, pain, use of orthoses, walking ability, forefoot function, and patient satisfaction of patients with RA who had undergone a complete forefoot correction of metatarsophalangeal (MTP) I to V. The study only included participants with RA before the era of biological agents and who were at least 20 years postoperatively. A total of 60 patients who had undergone 100 complete forefoot operations according to Tillmann 24.6 ± 3.5 years ago were included in this study. Results: The data collected showed that 35 reoperations were performed on 26 of the patients. Deformity relapses were often documented for the hallux valgus. More than 60% of the patients were able to wear conventional shoes. The distances the participants were able to walk were significantly increased by wearing shoes when compared with walking barefoot ( P < .01). Conclusion: While forefoot function remained difficult to assess, the majority of patients were able to use conventional shoes. This long-term follow-up study of patient-reported questionnaires completed more than 20 years after the Tillmann procedure showed that more than 80% of the patients remained satisfied with the outcome. Level of Evidence: Level IV, retrospective cohort study.

The Occurrence of Ipsilateral or Contralateral Foot Disorders and Hand Dominance

Background: To our knowledge, hand dominance and side of foot disorders has not been described in the literature. We sought to evaluate whether hand dominance was associated with ipsilateral foot disorders in community-dwelling older men and women. Methods: Data were from the Framingham Foot Study (N = 2,089, examined 2002–2008). Hand preference for writing was used to classify hand dominance. Foot disorders and side of disorders were based on validated foot examination findings. Generalized linear models with generalized estimating equations were used to estimate odds ratios and 95% confidence intervals, accounting for intraperson variability. Results: Left-handed people were less likely to have foot pain or any foot disorders ipsilateral but were more likely to have hallux valgus ipsilateral to the left hand. Among right-handed people, the following statistically significant increased odds of having an ipsilateral versus contralateral foot disorder were seen: 30% for Morton’s neuroma, 18% for hammer toes, 21% for lesser toe deformity, and a twofold increased odds of any foot disorder; there was a 17% decreased odds for Tailor’s bunion and an 11% decreased odds for pes cavus. Conclusions: For the 2,089 study participants, certain forefoot disorders were shown to be ipsilateral and others were contralateral to the dominant hand. Future studies should examine whether the same biological mechanism that explains ipsilateral hand and foot preference may explain ipsilateral hand dominance and forefoot disorders. (J Am Podiatr Med Assoc 103(1): 16–23, 2013)