Pathogenesis of the Hallux Valgus: Enthesopathy of the Metatarsosesamoid Ligament

Abstract

Category: Bunion; Basic Sciences/Biologics Introduction/Purpose: It is generally accepted that failure of the medial supporting soft tissue structure of the metatarsophalangeal joint plays an important role in the development of hallux valgus. The metatarsosesamoid ligament (MSL), a component of the medial soft tissue, is an important structure that connects the metatarsal head and the sesamoid complex. The sesamoid complex works as a dynamic stabilizer of the metatarsal head. We hypothesized that the failure of the medial MSL causes instability of the first metatarsal bone, which leads to hallux valgus deformities. Therefore, the present study aimed to describe the detailed structure and degenerative findings of MSL and to clarify the mechanical stress of the MSL enthesis, considering the mechanism of failure of the medial supporting soft tissue structure. Methods: The first metatarsal heads and sesamoid bones with soft tissue were collected from twelve cadavers. Serial 4-μm thick section4-μm intervals and stained with toluidine blue (Fig. 1a). We described the detailed histological structures and degenerative findings of MSL. In addition, morphometric comparisons were made between the medial and lateral MSL entheses at the metatarsal head to evaluate the mechanical stress they. First, we measured the thickness of the uncalcified fibrocartilage (UF thickness) following a protocol adopted previously (Fig. 1b). Second, the degree of irregularity of the interface between the zones of calcified fibrocartilage and bone (CFB) at each enthesis was assessed as the ratio between the lengths of the CFB and the enthesis (CFB/ E ratio) (Fig. 1c). The differences in these parameters were evaluated using the paired T test and Wilcoxon signed-rank test (P < 0.05). Results: We identified that the MSL entheses were fibrocartilaginous entheses, which consisted of four tissue zones. The region in which the MSL wraps around the articular surface of the metatarsal head contains a metachromatic area accompanied by fibrocartilage cells at the deep surface of the MSL, called the sesamoid fibrocartilage. At the MSL enthesis, pathological findings indicating enthesopathy were observed. One specimen showed the tear of the MSL at the wrap around region. The MSL enthesis tear was observed in two specimens with hallux valgus. Both UF thickness (P = 0.12, effect size r = 0.89) and CFB/E ratio (P = 0.17, effect size d = 0.35) were significantly greater in the medial MSL enthesis than those in the lateral MSL enthesis. Conclusion: In the present study, the MSL showed enthesis protecting structures such as enthesis fibrocartilage which contributes to dissipating bending forces during insertional angle change, complexed CFB interface which guards an enthesis against shearing forces and wrap around region which contributes to dissipating the shearing force to the enthesis. However, the medial MSL subject to the greater forces and the degenerative findings of enthesopathy were observed. On top of that, all four hallux valgus specimens with sesamoid complex dislocation showed MSL enthesis tear. Enthesopathy, particularly at the medial MSL, may be the cause of hallux valgus.