Metatarsophalangeal Joint Instability Research Articles

Outcomes of Surgical Management of Turf Toe: 12-Year Results.

Background "Turf toe" is a classical capsuloligamentous injury to the plantar surface of the metatarsophalangeal (MTP) joint of the great toe. The name is synonymous with injuries sustained on artificial turf or hard grounds. The classical injury pattern is a hyperdorsiflexion injury with an axial load. The outcomes of these injuries are unpredictable and there are no clear guidelines for the management of these injuries. These injuries are debilitating and can lead to long-term problems and inability to return to pre-injury activity level if missed. We present a long-term surgical follow-up of severe grade 3 turf toe injuries. Methods In the period from 2011 to 2022, we treated 20 patients with turf toe/MTP joint instability. There were 10 football injuries (50%), six running injuries (30%), two gymnastic injuries (10%), one motorcycle injury (0.5%), and one was a ballet dancer (0.5%). All the grade 1 and 2 injuries were treated conservatively with rest, ice application, and splinting of the toe. Grade 3 injuries were treated surgically and strict rehabilitation protocol was followed. Results The mean age at surgery was 32.7 years and the average patient follow-up was 7.5 months after surgery. The Manchester-Oxford Foot Questionnaire (MOXFQ) score showed a statistically significant improvement from a mean of 73.0 (median = 75) preoperatively to 28.1 (median = 28.6) postoperatively (median improvement = 46.4, P = 0.022). Similarly, there was a significant improvement in pain score, which showed an improvement from a mean of 72.9 (median = 70.0) preoperatively to a mean of 22.9 (median = 25.0) postoperatively (median improvement = 51.3, P = 0.022). Conclusion Turf toe is a serious injury that may prevent a high percentage of patients from resuming their previous physical activities. The correct identification, classification, and grading of the first MTP joint instability helps in decision-making and achieving good surgical outcomes.

Ultrasonography-Based Quantitative Evaluation of Second Metatarsophalangeal Joint Instability in Female Patients With Hallux Valgus.

Patients with moderate to severe hallux valgus (HV) sometimes exhibit second metatarsophalangeal (MTP) joint dislocation. Second MTP joint instability due to plantar plate (PP) injury has been suggested as one of the causes. However, there have been no reports that quantitatively evaluate this instability. This study aimed to evaluate second MTP joint instability in patients with HV without dislocation via ultrasonography and investigate its relationship with the presence of PP injury or foot form. Between May 2018 and July 2023, symptomatic female patients with HV without any lesser toe deformity were included in this study. Second MTP joint instability was defined as the dorsal displacement ratio (DDR) of the passively subluxated proximal phalangeal articular surface on the metatarsal head articular surface. The presence of PP injury was assessed using ultrasonography. Foot "form" was determined by measuring standard foot bony angles on weight-bearing foot-ankle radiographs. The relationship between DDR or PP injury and radiographic measurements was investigated. Sixty-four patients (100 feet) were included. The average DDR of the second MTP joint in patients with HV without dislocation was 35.7%. There was an increase in the probability of PP injury, above a cutoff DDR value r of 35.4% (area under the curve = 0.712). The sensitivity, specificity, positive predictive value, and negative predictive value for the presence of PP injury based on this cutoff level were 63.9%, 74.4%, 79.6%, and 56.9%, respectively. Metatarsalgia was reported in 21 feet (21.0%), of which 15 feet (71.4%) showed PP injury. An increase in DDR was weakly associated with increased metatarsus adductus angle and decreased second metatarsal height. In female patients with HV without second MTP dislocation, we found ultrasonographic evidence of second MTP plantar plate injury and joint instability to be a relatively common finding with a high prevalence in those with localized metatarsalgia. Level II, development of diagnostic criteria based on consecutive patients.

Early Outcomes Following Plantar Condylectomy and Imbrication of Plantar Plate to Metatarsal Neck for Metatarsalgia and Grade 0 Lesser Toe Metatarsophalangeal Joint Instability

Background: Metatarsalgia and plantar plate tears are characterized by forefoot pain and toe deformity in severe cases. Conservative management may slow progression of symptoms; however, definitive treatment often requires operative intervention. The purpose of this observational study was to evaluate the combination of plantar condylectomy and surgical imbrication of the plantar plate to the metatarsal neck to repair grade 0 plantar plate injuries. Methods: We retrospectively identified 22 patients with metatarsalgia and low-grade plantar plate lesions (grade 0), operated between 2018 and 2021, who underwent operative repair involving plantar metatarsal condylectomy and proximal surgical imbrication of the plantar plate to the metatarsal neck. Fourteen patients underwent concomitant hallux valgus correction. Data collection was performed preoperatively and postoperatively and included Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) and pain interference (PI) scores. Paired Wilcoxon signed-rank tests compared PROMIS PF and PI scores at patients’ preoperative, 6-9-week, 3-4-month, 5-6-month, and ≥9-month follow-up evaluations ( P < .05). Results: Compared to their preoperative visit, patients demonstrated modest improvement in their PROMIS (pain and physical function) scores over the first ≥9 months postoperatively (median 13.0 months). Median preoperative and most recent PROMIS physical function scores were 40.5 (95% CI: 36-49) and 44.5 (95% CI: 40-52), respectively. Median PROMIS pain interference scores changed from 62.5 (95% CI: 56-67) to 56.0 (95% CI: 51-62). Improvement in pain and function was sustained in patients available for postoperative follow-up. Conclusion: In this small, early follow-up series, we found that plantar condylectomy and surgical imbrication of the plantar plate to the metatarsal neck was modestly helpful to treat metatarsalgia and grade 0 plantar plate injuries. Level of Evidence: Level IV, retrospective case series.

Claw Toe With Dislocated Second Metatarsophalangeal Joint: Treated by Plantar Plate Tenodesis and Release of Collateral Ligaments

Claw toe deformity of the second toe is a common forefoot deformity faced by foot and ankle surgeons. Frequently, it develops as the result of plantar plate insufficiency and subsequent metatarsophalangeal (MTP) joint instability. As the disease deteriorates, the MTP joint can be dislocated. Reduction of the MTP joint without metatarsal osteotomy seems to be a logical approach unless there is excessively long second metatarsal. However, adequate periarticular soft-tissue release including the dorsal capsule, collateral ligaments and extensor tendon is needed to reduce the intra-articular pressure and minimize the risk of joint degeneration. The purpose of this Technical Note is to describe the details of plantar plate tenodesis and release of collateral ligaments for correction of claw second toe associated with dislocation of the metatarsophalangeal joint.

Direct Plantar Approach to Plantar Plate Repair and Associated Wound Complications.

Lesser toe metatarsophalangeal joint (MTPJ) instability, secondary to plantar plate tear, has been the focus of numerous recent publications, the majority reporting on repair through a dorsal approach. A plantar approach has been described with the advantage of direct ligamentous repair or repair to bone, which follows conventional techniques employed throughout the body. Previous clinical studies have shown success in deformity correction and the longevity of both approaches. The proponents of the dorsal approach advocate that indirect repair of the plantar plate avoids perceived risks of complications with a plantar incision without evidence of superior outcomes. The purpose of this study was to investigate the safety and efficacy of the direct plantar approach to plantar plate repairs (PPRs) by reporting the rate of specific complications in a large clinical series. This was the institutional review board (IRB) approved retrospective study of 204 PPRs in 185 patients (194 lesser MTP, 10 hallux MTP) with an average age of 56 and a mean body mass index (BMI) of 28. Surgical technique involved repair with absorbable braided suture (88%) versus suture anchor (12%) with or without MTPJ pinning (80%). Mean follow up was 53 weeks (range 5-170). Patients were screened for associated risk factors, including diabetes mellitus (8%), tobacco use (5%), neuropathy (1%), and additional concurrent procedures (96%). Complications were defined as superficial or deep infection, painful scars, and reoperation. Analysis was conducted using the Wilcoxon-Mann-Whitney test or Fisher's exact tests for continuous and categorical variables, respectively. Risk factors were analyzed using univariate logistic analysis to produce odds ratios (OR) with a 95% confidence interval (CI) and an inclusion criterion of a P-value, P > .2 for multivariate analysis as determined by Wald tests (significance at P < .05 for final modeling). Overall, there were 31 total complications (15%) demonstrated by 14 superficial infections (6.8%) and 17 painful scars (8.3%) along with three reoperations (1.4%). All reoperations were performed for deformity or instability, not scar revision. There were no deep infections. No increased odds of complications were found with suture anchor repair, MTPJ pinning, neuropathy, or diabetes. Patients that used tobacco had 7.5 (CI 1.66, 34.06) the odds of developing any wound complication compared with nonsmokers. Tobacco use was also found to significantly increase the odds of superficial infection by 9.8 (CI 2.08, 46.15). There was no increase in painful scars or reoperation in tobacco users. This study did not find an increased complication rate with additional ipsilateral procedures performed at the time of surgery. To our knowledge, this is the largest study evaluating the direct plantar approach to PPR as well as the evaluation of associated complications with the plantar incision. With low complication and minimal reoperation rates, the results of this study have demonstrated the clinical viability of plantar-based incisions. Previous studies have demonstrated the success of PPR and correction of deformity with a direct approach. This case series further demonstrates the safety and efficacy of plantar-based incisions, particularly for direct PPRs. IV Retrospective Case Series. Lesser Toes.

Surgical Imbrication of Plantar Plate to Metatarsal Neck in the Setting of Lesser Toe Metatarsophalangeal Joint Instability

Category:Lesser Toes; Midfoot/ForefootIntroduction/Purpose:Persistent metatarsalgia refractory to non-operative therapy with accompanying plantar plate injury represents a common and challenging treatment problem. In previous studies, radiofrequency shrinkage has been used for the treatment of MTP joint instability secondary to low-grade plantar plate lesions.1 In the shoulder, this technique shows histological evidence of modest regenerative capacity but is also associated with several chronic sequelae including capsular stretching, nerve damage, recurrent instability, adhesive capsulitis, and thermally-induced chondrolysis.2-6 The purpose of this observational study was to examine the efficacy of surgical imbrication of the plantar plate to the metatarsal neck as a novel, cost-effective approach to repair Grade 0-1 plantar plate injuries. We sought to characterize patient-reported and radiographic outcomes in patients undergoing this procedure.Methods:Patients from a single fellowship-trained orthopaedic surgeon (1/2017 - 12/2020) were screened by electronic medical record review. Inclusion criteria were age >18 years, a pre-operatively measured Patient-Reported Outcomes Measurement Information System (PROMIS) score, a Grade 0 or 1 plantar plate tear discovered at time of surgery, and repair via surgical imbrication to the metatarsal neck. PROMIS Physical Function and Pain Interference scores were obtained from 14 enrolled patients (median age was 55 years; range: 40-69; 12 female) post-operatively at 6-9 weeks, 3 months, 6 months, and 1-2 years.Basic demographic information and pertinent medical information were also obtained. Three fellowship-trained orthopaedic surgeons independently reviewed radiographs to assess reduction of the metatarsophalangeal joint, and joints were graded as reduced, subluxated, or dislocated. Wilcoxon signed-rank tests compared pre- and post-operative PROMIS scores. Changes in PROMIS scores were compared to numerical and categorical patient characteristics via univariate linear regressions and Mann- Whitney U-tests, respectively.Results:Median postoperative times to most recent PROMIS score and radiographs were respectively 13.0 months (95% confidence interval: 10.0-21.4) and 7.6 months (2.9-10.0). Median preoperative and most recent Physical Function scores were 39.5 (35-50) and 52.5 (41-62), respectively (p=0.003), and median Pain Interference scores changed from 61.0 (56-68) to 53.5 (39- 58) (p=0.002) (Fig. 1). Changes in PROMIS scores showed no association with BMI, age, preoperative opioid use, wound complications, concomitant dislocation, fibromyalgia, or mood disorder (p>0.10). Preoperatively, 9 second MTP joints were concentrically reduced, and 5 were subluxated (n=14). At 6 weeks post-operation, 13 joints remained reduced (n=14). At most recent measurement, all (n=10) joints were reduced (4 patients missing data). 9 of 14 patients underwent concomitant correction of hallux valgus at time of surgery.Conclusion:Patients with Grade 0-1 plantar plate injuries improved significantly in radiographic parameters and patient reported outcome scores following surgical imbrication of the plantar plate to the metatarsal neck. This procedure represents a novel, alternative approach that is both efficacious and cost-effective. Our work contributes valuable surgical outcomes data to a limited knowledgebase regarding pathophysiology and management for low-grade plantar plate lesions in MTP joint instability. Future work will involve larger, prospective studies to better understand outcomes of and indications for this approach.

Ultrasound findings of plantar plate tears of the lesser metatarsophalangeal joints.

Lesser metatarsophalangeal (MTP) joint plantar plate tears are a common and increasingly recognised cause of metatarsalgia, MTP joint instability and forefoot deformity. Increased interest in early accurate diagnosis of plantar plate tears follows recent surgical innovations allowing direct plantar plate repair. The purpose of this review is to describe the ultrasound features of normal lesser MTP joint plantar plates and to characterise and illustrate the direct and indirect ultrasound findings of plantar plate tears. Lesser MTP joint plantar plate tears are most commonly located at the 2nd MTP joint, involving the lateral distal plantar plate insertion with variable propagation medially and proximally. The most common ultrasound appearance of a plantar plate tear is a discrete partial or full thickness hypoechoic defect in the plate substance. Flattening and attenuation or non-visualisation of the plantar plate represent more extensive tears. Dynamic imaging with toe dorsiflexion improves visualisation of tears and augments MTP joint subluxation. A common indirect finding is pericapsular fibrosis along the MTP joint capsule adjacent to a plantar plate tear, which requires differentiation from Morton's neuroma, and key distinguishing features at ultrasound are described. Other indirect findings include the cartilage interface sign, flexor tendon subluxation onto the metatarsal head or medial to the midline, flexor tenosynovitis, proximal phalangeal enthesophytes or avulsion and MTP joint synovitis. Ultrasound offers several advantages over MR imaging but requires a meticulous ultrasound examination, and optimisation of scanning technique is described.

Direct Plantar Approach to Plantar Plate Repair and Associated Wound Complications

Category:Lesser ToesIntroduction/Purpose:Lesser toe metatarsophalangeal joint instability, secondary to plantar plate tear, has been the focus of numerous recent publications, majority reporting on repair through a dorsal approach. A plantar approach has been described with the advantage of direct ligamentous repair or repair to bone, which follows conventional techniques employed throughout the body. Previous clinical studies have shown success in deformity correction and longevity of both approaches. The proponents of the dorsal approach advocate that indirect repair of the plantar plate avoids perceived risks of complications with a plantar incision, without evidence of superior outcomes. The purpose of this study was to investigate the safety and efficacy of direct plantar approach to plantar plate repairs by reporting the rate of specific complications in a large clinical series.Methods:This was an IRB approved retrospective study of 204 plantar plate repairs, in 185 patients, (194 lesser MTP, 10 hallux MTP) with average age of 56 and mean BMI of 28. Surgical technique involved repair with absorbable braided suture (88%) versus suture anchor (12%) with or without MTPJ pinning (80%). Mean follow up was 53 weeks (range 5-170). Patients were screened for associated risk factors including diabetes mellitus (8%), tobacco use (5%), neuropathy (1%) and additional concurrent procedures (96%). Complications were defined as superficial or deep infection, painful scar, and reoperation. Analysis was conducted by using Wilcoxon-Mann-Whitney test or Fisher’s exact tests for continuous and categorical variables, respectively. Risk factors were analyzed using univariate logistic analysis to produce odds ratios (OR) with 95% confidence interval (CI) and an inclusion criterion of a p-value > 0.2 for multivariate analysis as determined by Wald tests (significance at p<0.05 for final modeling).Results:Overall, there were 31 total complications (15%) demonstrated by 14 superficial infections (6.8%) and 17 painful scars (8.3%) along with three reoperations (1.4%). All reoperations were performed for deformity or instability, not scar revision. There were no deep infections. No increased odds of complications were found with suture anchor repair, MTPJ pinning, neuropathy, or diabetes. Patients that used tobacco had 7.5 (CI 1.66- 34.06) the odds of developing any wound complication compared with nonsmokers. Tobacco use was also found to significantly increase the odds for superficial infection by 9.8 (CI 2.08 - 46.15). There was no increase in painful scar or reoperation in tobacco users. This study did not find an increased complication rate with additional ipsilateral procedures performed at the time of surgery.Conclusion:To our knowledge, this is the largest study evaluating the direct plantar approach to plantar plate repair, as well as the evaluation of associated complications with the plantar incision. With low complication and minimal reoperation rates, the results of this study have demonstrated the clinical viability of plantar based incisions. Previous studies have demonstrated the success of plantar plate repair and correction of deformity with a direct approach. This case series further demonstrates the safety and efficacy of plantar based incisions, particularly for direct plantar plate repairs.

Mallet Toes, Hammertoes, Neuromas, and Metatarsophalangeal Joint Instability: 40Years of Development in Forefoot Surgery.

Today's foot and ankle surgeon has an enhanced understanding of forefoot pathology and treatment options compared to surgeons who practiced in previous decades. This paper summarizes developments in forefoot surgery in the past 40 years, specifically in treatments for mallet toe, hammertoe, neuroma, and metatarsophalangeal joint instability. A review of the literature was conducted using the PubMed search engine, with key terms including, "mallet toe," "hammertoe," "neuroma," "metatarsophalangeal joint instability," "plantar plate," and "forefoot surgery." Chapters in major orthopaedic textbooks covering these topics were also reviewed. We then chronicled the history of the diagnosis and treatment of these pathologies, with a focus on the past 40 years. There have been major advances in understanding and treating forefoot pathologies in the past four decades; however, there remain areas for improvement both in the diagnosis and treatment of these problems. Level V, meta-synthesis.

Forefoot Injuries in Sports

Forefoot injuries are common injuries in high-impact sports. The forefoot experiences a large amount of stress during the late stance phase of the gait cycle. Repetitive load applied to the forefoot without adequate rest can lead to tissue breakdown, resulting in injury. Forefoot sporting injuries can deteriorate gait function, sporting performance, and quality of life. In this article, we review the typical presentation, approach, and treatment modalities of the commonest forefoot sporting injuries. These include metatarsal stress fractures, second metatarsophalangeal joint (MTPJ) instability, turf toe injury, sesamoid pathologies, as well as hallux valgus and rigidus. Metatarsal stress fractures are frequent overuse injuries. They can be managed conservatively with activity modification and protected weight-bearing or surgically with open internal fixation. Second MTPJ instability typically involves disruption of the second MTPJ ligamentous joint capsule. Management of this condition includes customized orthotics, physiotherapy, hydrocortisone and lignocaine (HL7(2):50–56.

First MTP joint instability — Expanding the concept of “Turf-toe” injuries

BackgroundAlthough the classic definition of the Turf-toe injury refers to a very specific clinical and pathological picture, we think that the concept can be broadened to encompass a wide variety of traumatic lesions of the first metatarsophalangeal joint (MTP1). These are lesions typically difficult to diagnose, with a large variation of outcomes and a potential to impair patients’ functional performance on a definitive and perennial basis. The objective of this study is to present the result obtained by treating 24 cases of traumatic injuries to the MTP1 joint in a midterm follow-up time. MethodsIn the period from 1999 to 2016, 24 patients were treated with MTP1 joint instability – “Expanded Turf-toe” – diagnosis. All patients were performing sports activities when they were injured: soccer (33%); martial arts (17%); running (13%); tennis (8%); olympic gymnastics (8%) and others (basketball, slalom, motorcycling, surfing, and ballet) (21%). Injuries were classified as Grade I (2 patients — 8%), Grade II (8 patients — 33%) and Grade III (14 patients — 59%) lesions. All patients with grades I and II were treated conservatively whereas those classified as grade III were treated surgically. ResultsAfter an average follow-up of 4.5 years we observed an improvement in the AOFAS hallux score from 42 to 82 points after treatment (p<0.001). The most frequent cause was axial load with various direction of stress at the first MTP. The mechanism of lesion varied among extension with hallux varism (42%), pure hyperextension (25%), extension with hallux valgism (21%), pure hyperflexion (8%) and hyperflexion with hallux valgism (4%). A separate analysis of each group showed a significant improvement in AOFAS Hallux scores after treatment: 51–84 (p<0.001) and 36–81 (p<0.001) for conservative and surgical groups, respectively. Four patients with GIII injuries (29%) and two with GII injuries (20%) did not resume their previous activities. Although pre-treatment AOFAS hallux scores were significantly different between groups, post-treatment scores were similar (p=0.615). ConclusionsTurf-toe is a serious injury that may prevent a high percentage of patients from resuming their previous physical activities. Mechanism of lesion might be varied generating a wide range of lesions that fit into the expanded concept of the Turf-toe injury. Both forms of treatment lead to satisfactory results if well conducted. The correct identification, classification, and grading of first metatarsophalangeal joint (MTP) instability helps in decision making and selection of the adequate treatment.Level of evidence: Level IV, retrospective case series.

Radiographic predictors for improved outcomes after hammertoe correction surgery

Category: Lesser Toes Introduction/Purpose: Hammertoe deformities are common, often painful deformities of the lesser foot and are known to severely affect daily activities. When patients seek surgical management, x-rays are utilized for diagnosis, evaluation for surgical candidacy, and selection of the operative technique. Postoperatively, radiographs are retaken to assess bone health, healing status, and alignment. Despite the frequent use of radiographs pre- and post-operatively, radiographic results are not necessarily indicative of clinical presentation or surgical outcomes. The aim of this study is to identify specific radiographic parameters that are predictive of improved pain and function after surgical correction of hammertoe deformity. Methods: Prospectively collected data was reviewed on 51 consecutive patients who underwent operative correction of hammertoe deformity. Patient demographics, comorbidities, and post-surgical complications were recorded from their electronic medical records. Clinical outcomes were assessed utilizing preoperative and postoperative Visual Analogue Scale (VAS) and Short Form Health Survey Physical Component (SF-36 PCS) scores with a minimum of six-month follow-up. Radiographs were scored by a foot &amp; ankle fellowship-trained orthopaedic surgeon to assess preoperative severity, postoperative joint fusion, and both pre- and postoperative joint instability and arthritis. Data was examined using a multivariable analysis. Results: Preoperatively, 15.7% (8/51) of patients had a deformity classified radiographically as mild, 37.3% (19/51) as moderate, and 47.1% (24/51) as severe. Additionally, 60.8% (31/51) had joint instability, 17.7% (9/51) had joint dislocation, and 7.8% (4/51) had joint arthritis. Postoperatively, 74.5% had PIP joint fusion, 35.3% (18/51) had joint arthritis, and 9.8% (5/51) had joint instability. A significant association was found between PIP joint fusion and improved SF-36 PCS scores (p=.004). Preoperative anticoagulant therapy was associated with reduced rates of PIP joint fusion (p=0.02). There was no association found between the other demographic or radiographic parameters, and no parameters were associated with improvement in VAS scores. Conclusion: After undergoing surgical correction of hammertoe deformity, postoperative PIP joint fusion was the only variable determined to be indicative of improved physical function. However, pre- and postoperative metatarsophalangeal joint arthritis nor instability was predictive of outcomes. This work informs foot &amp; ankle specialists that healing of the PIP joint is critical to successful hammertoe surgery.

IATROGENIC HALLUX VARUS: CAUSES OF DEFORMITY AND POSSIBILITIES OF PERCUTANEOUS SURGICAL CORRECTION (RETROSPECTIVE ANALYSIS OF CASE REPORTS)

Introduction. Hallux varus is a relatively rare foot deformity. Commonly, hallux varus is a complication after the hallux valgus surgery and typically is the result of the first metatarsal medial eminence over resection, first and second metatarsal excessive convergence, over release of the lateral soft tissues, overtightening of the medial soft tissues and soft tissue imbalance of the first metatarsophalangeal joint.The purpose of this study was to clarify the causes and timing of the iatrogenic hallux varus formation and to evaluate the possibility and efficiency of percutaneous techniques in its surgical treatment.Material and methods. Thirty-one feet (31 females suffering from iatrogenic hallux varus) were examined clinically and radiologically, including 14 patients who underwent surgery. The average age of the whole group was 57 years (range, 39 to 74), the subgroup of operated patients — 60 years (range from 53 to 68). The time after primary interventions before the examination varied from 2 to 44 years. The mean follow-up after surgery was 6 months (range from 1.5 to 54).Results. No infection or wound-healing issues were observed. Overall, the patients were completely satisfied with the outcomes of 12 surgeries and satisfied with reservation in 2 cases.Conclusions. The visual manifestations of hallux varus are determined not only by the hallux varus angle, but also by the value of the first intermetatarsal angle. In addition to well-known factors, hallux varus formation is determined by first metatarsal bone elongation and first metatarsophalangeal joint instability. In rare cases, only one of the factors leads to the hallux varus; as a rule, we see a combination of factors with their mutual reinforcement. Despite the demonstration of usage possibility and the efficiency of percutaneous techniques in hallux varus correcting, a small number of observations in the study does not yet allow giving recommendations on the use of specific percutaneous techniques depending on the various clinical manifestations of hallux varus.

Angiology of the Plantar Plate

Category: Basic Sciences/Biologics, Lesser Toes, Midfoot/Forefoot Introduction/Purpose: Hammertoes, crossover toes, and claw toes are common deformities and can be a major source of pain and dysfunction. These deformities result from instability of the metatarsophalangeal (MTP) joint due to incompetence of the plantar plate and/or collateral ligaments. Non-operative management is the first line of treatment. When non-operative treatment is unsuccessful, surgical interventions have been described. Newer surgical techniques focus on performing anatomic repairs of plantar plates. The vasculature of the foot has been well studied, but the vascular supply of the plantar plate has not been described. This study presents a new technique for imaging the microvasculature of the lesser toe plantar plates through micro- computed tomography (micro-CT) in order to better understand tear pathology and the capacity of healing with plantar plate repairs. Methods: The posterior tibial and dorsalis pedis arteries of a fresh frozen human cadaver foot were dissected and cannulated at the ankle for perfusion distally. After administration of an anticoagulant, each artery was perfused with Microfil® Silicone Rubber, a contrast agent. The compound was then allowed to cure, and the foot was fixed in formalin. The foot was sectioned through the metatarsal shafts for imaging, and imaging of the lesser toe MTP joints was performed using a Bruker Skyscan 1176 micro-CT scanner at 18 micron slices. Computerized reconstruction of the images was performed for three dimensional visualization of the vasculature. Results: Post-perfusion imaging of the lesser toe MTP joints using micro-CT allows for visualization of the plantar plate microvasculature. Preliminary imaging suggests that micro-CT is a useful modality for analysis of the blood supply of the plantar plate. Conclusion: Anatomic repair of the plantar plate has become a viable treatment option for MTP joint instability. One important question that remains to be answered is whether plantar plate tears have the capacity to heal. We present a novel technique for imaging of lesser toe plantar plate microvascularity using micro-CT. Preliminary results of post-perfusion imaging of the plantar plate are promising for developing a better understanding of its blood supply. Further definition of the plantar plate vascular supply will help clinicians understand the capacity for healing after repairs and may provide some insight to the biological causes plantar plate tears.

Modified Surgical Correction of Over-riding Second Toe

An Overriding toe is a deformity of the lesser toes and which commonly affects the second toe with unclear aetiology. It is speculated to be multifactorial. There are multiple factors leading to metatarsophalangeal joint (MTPJ) instability. These are attributed to chronic inflammation of the synovium, capsule overuse as well as muscle imbalance from neuromuscular disorder and a long second metatarsal bone. These can all result in an overriding toe deformity.

Second and Third Metatarsophalangeal Plantar Plate Tears: Diagnostic Performance of Direct and Indirect MRI Features Using Surgical Findings as the Reference Standard.

The objective of our study was to assess the diagnostic performance and associations of the direct and indirect MRI features of the metatarsophalangeal (MTP) joint that are thought to be related to tears of the plantar plate (PP) using surgical findings as the reference standard. We retrospectively included 23 patients with symptomatic instability of lesser MTP joints who had undergone preoperative 1.5-T MRI and surgical assessment. The MRI examinations were independently assessed by two musculoskeletal radiologists. Using the surgical data as the reference standard, we calculated the sensitivity, specificity, and accuracy of each MRI feature in the detection of PP tears. Multivariate logistic regression analysis was performed to identify which MRI features were independently associated with PP tears. Interobserver reliability was assessed using kappa statistics. Forty-five lesser MTP joints were included. The presence of pericapsular fibrosis was highly sensitive (91.2%), specific (90.9%), and accurate (91.1%) for the diagnosis of PP tears. With a cutoff value of 0.275 cm, the PP-proximal phalanx distance had a sensitivity of 64.7%, specificity of 90.9%, and accuracy of 71.1% in diagnosing PP tears. In patients with clinical features indicating lesser MTP joint instability, some direct and indirect MRI features exhibited good to excellent diagnostic performance in detecting the presence of PP tears.

Plantar Plate Repair for Lesser Metatarsophalangeal Joint Instability.

Lesser metatarsophalangeal (MTP) joint instability is a common cause of forefoot pain. Advances in operative technique and instrumentation have made it possible to anatomically treat plantar plate tears through a dorsal approach. Our goal was to evaluate the subjective, functional, and radiographic outcomes of plantar plate repair (PPR) from a dorsal approach. A prospective case series was performed evaluating the results of PPR in 97 feet with 138 plantar plate tears. Patients underwent PPR from a dorsal approach with a Weil osteotomy. We followed patients at regular intervals for 12 months and collected data preoperatively and postoperatively with respect to visual analog scale (VAS) scores, MTP range of motion (ROM), paper pull-out test, American Orthopaedic Foot & Ankle Society (AOFAS) scores, satisfaction, and radiographic measures. Eighty percent of patients scored "good" to "excellent" satisfaction scores at 12 months. The mean VAS pain score preoperatively was 5.4/10, and postoperatively was 1.5/10. The mean AOFAS scores increased from 49 to 81 points following surgery. The mean MTP ROM preoperatively was 43 degrees and postoperatively 31 degrees. Forty-two percent of toes passed the paper pull out test prior to surgery and 54% at 12 months. Mean metatarsal shortening was 2.4/3.1/1.2 mm for the second, third, and fourth metatarsals, respectively. The mean MTP joint angles preoperatively were 2/4.9/-1.3 degrees and postoperatively were 7.4/9.6/0.2 degrees, respectively, for the second, third, and fourth MTP joints. We found that the plantar plate could be repaired through a dorsal approach with reliable outcomes. PPR was a viable option to anatomically restore the ligamentous support in the unstable lesser MTP joint. Level IV, retrospective case series.

Correction of Crossover Toe Deformity by Arthroscopically Assisted Plantar Plate Tenodesis

Plantar plate deficiency is the major pathology causing metatarsophalangeal joint instability. As the joint subluxates dorsally, the lumbrical is tethered at the medial side of the joint by the deep metatarsal ligament and becomes a deforming force for the development of crossover toe deformity. Plantar plate repair or reconstruction is a logical surgical treatment option. This can be performed through a dorsal or plantar approach. The purpose of this technical note is to report a minimally invasive technique of crossover toe deformity correction by suturing the plantar plate to the extensor tendon. It is indicated for symptomatic crossover toe deformity that is not responsive to nonsurgical treatment. It is contraindicated if the metatarsophalangeal joint is degenerated, destructed, or dislocated, or there is interdigital neuroma at the sides of the deformed toe, or the deformity is caused by bony deformities of the metatarsal head or the proximal phalanx.

CT and MR Imaging of the Postoperative Ankle and Foot.

A variety of surgical procedures exist for repair of both traumatic and degenerative osseous and soft-tissue pathologic conditions involving the foot and ankle. It is necessary for the radiologist to be familiar with these surgical procedures, so as to assess structural integrity, evaluate for complicating features, and avoid diagnostic pitfalls. Adequate interpretation of postoperative changes often requires access to surgical documentation to evaluate not only the surgery itself but the expected timeline for resolution of normal postoperative changes versus progressive disease. Appropriate use of surgical language in radiology reports is another important skill set to hone and is instrumental in providing a high-quality report to the referring surgeons. The pathophysiology of a myriad of surgical complaints, beginning from the Achilles tendon and concluding at the plantar plate, are presented, as are their common appearances at computed tomography and magnetic resonance imaging. Commonly encountered entities include Achilles tendon tear, spastic equinus, nonspastic equinus, talar dome osteochondral defect, tarsal tunnel syndrome, plantar fasciitis, pes planovalgus, pes cavovarus, peroneal tendinosis, lateral ligament complex pathology, Morton neuroma, plantar plate tear, and metatarsophalangeal joint instability. Computer-generated three-dimensional models are included with many of the procedures to provide a more global view of the surgical anatomy. Correlation with intraoperative photographs is made when available. When appropriate, discussion of postoperative complications, including entities such as infection and failure of graft integration, is presented, although a comprehensive review of postoperative complications is beyond the scope of this article. Notably absent from the current review are some common foot and ankle procedures including hallux valgus and hammertoe corrections, as these are more often evaluated radiographically than with cross-sectional imaging. ©RSNA, 2016.

Modified double plantar plate tenodesis.

Metatarsophalangeal joint instability of the lesser toe can cause acquired toe deformity. Plantar plate deficiency is the major pathology. Plantar plate repair can stabilize the joint but may result in iatrogenic transverse plane toe deformity in correction of claw toe deformity. Limited toe extension can be resulted after correction of crossover toe deformity by plantar plate tenodesis and extensor digitorum brevis transfer. A modification of the technique is proposed. The clinical outcomes of 10 patients with the modified procedure performed were assessed. The correction was full in all toes with no recurrence. The modified technique can stabilize the metatarsophalangeal joint and correct lesser toe deformity without the need of tendon transfer, osteotomy or sophisticated instrumentation.