Background: Arthrodesis of the first metatarsophalangeal (MTP) joint is a well-established procedure with excellent outcomes for patients with forefoot disorders. Routine bone grafting is not typically required, but bone graft may be necessary in the setting of revision surgery. Because of potential harvesting morbidity and time associated with an extra incision, allograft bone is frequently used. In this study, we describe the outcomes of an approach to first MTP fusion with simultaneous medial sesamoidectomy for utilization as autograft. Methods: A retrospective review of all first MTP arthrodesis cases performed by one fellowship-trained foot and ankle surgeon were identified. Operative reports and radiographs were reviewed identifying patients who underwent simultaneous medial sesamoidectomy for autograft purposes. Indications for sesamoidectomy harvesting were noted. The primary outcome reviewed was fusion rate. Overall nonunion rates and patient outcomes were collected and compared between those undergoing sesamoidectomy for grafting and those undergoing standard procedure arthrodesis. Results: A total of 107 patients underwent first MTP arthrodesis. Of these, 24 underwent concurrent sesamoidectomy grafting with 9 requiring additional calcaneal grafting. Indications for the sesamoidectomy group included 5 primary cases of erosive hallux rigidus, 2 cases of hallux valgus, 6 nonunions, 3 failed Cartiva implants, 2 cases of avascular necrosis, 4 failed arthroplasties, and 2 conversion bunionectomy. All 24 patients in the sesamoidectomy group achieved successful union. For context, the broader cohort undergoing first MTP arthrodesis had a fusion rate of 92.1%. All patients in the sesamoidectomy group were satisfied with their surgical outcome. Conclusion: This study found highly successful fusion rates in a potentially higher risk population with the use of local autografting from the medial sesamoid. The medial sesamoid serves as a freely available, structurally supportive graft material for first MTP arthrodesis that can be readily harvested via the same incision, potentially reducing the need for additional graft sites. However, given the retrospective nature, single-surgeon cohort, and small sample size, further studies are warranted to confirm these findings and evaluate comparative outcomes. Level of Evidence: Level III, retrospective comparative study.

BACKGROUND:Surgeons may hesitate to apply external ring fixators (ERFs) due to perceived high clinical burden. This study aims to quantify the relative demand of ERFs compared with other common foot and ankle procedures. Understanding the demand of ERFs can provide insights into postoperative experiences, potentially decreasing intimidation of their use. METHODS:Patients undergoing ERF treatment, hallux valgus osteotomy (HVO), or lateral ligamentous reconstruction (LLR) were identified using current procedural terminology code search in a single surgeon database. A retrospective review at a single institution included patients undergoing one of the three surgeries between 2017 and 2023. Clinical burden was quantified using points of contact for each procedure, which included phone calls, portal messages/documented emails, in-person visits, and surgeries. Visits and surgeries were categorized as routine or unexpected. Quantified burden was then compared among the three groups. RESULTS:One hundred ninety-four patients were included in the study (81 LLR, 64 HVO, 49 ERF), and data were collected within 6-month postoperation. ERFs had 2.27 more total clinic visits than HVO (6.91 vs. 4.64; P < 0.0001) and 2.80 more than LLR (6.91 vs. 4.11; P < 0.0001). Overall, 0.42 more unexpected clinic visits were observed for ERF than for HVO (0.94 vs. 0.52; P = 0.06) and 0.84 more than LLR (0.94 vs. 0.1; P < 0.0001). An average of 0.6 unexpected surgeries were observed for ERF, compared with 0.09 for HVO (P < 0.0001) and 0 for LLR (P < 0.0001). CONCLUSION:Patients with an ERF did have more frequent encounters compared with control groups. This study provides guidance about the extent of potential clinical burden of ERF. Whether this increase is clinically notable would be to the discretion of the treating surgeon.

Congenital dislocation of the fifth metatarsophalangeal (MTP) joint can cause significant limitations in a patient’s ability to wear a closed shoe. Historic treatment has involved amputation of the digit or attempts at reconstruction. These techniques have had limited success with unreliable correction and/or unacceptable cosmesis. The authors present a detailed, methodical approach to reconstruction of this deformity with a stepwise algorithm that addresses both the bony and soft tissue components of the deformity. With this modern technique, reliable and satisfactory results can be expected.

Category: Midfoot/Forefoot; Lesser Toes Introduction/Purpose: Hammertoe deformities are commonly encountered and frequently require surgical intervention for pain relief and shoewear accommodation. Various techniques exist for surgical management, but proximal interphalangeal (PIP) joint fusion with Kirschner (K) -wire fixation remains an inexpensive, popular treatment. The decision to place a K wire that spans the metatarsophalangeal (MTP) joint versus only fixating the digit through the proximal phalanx is entirely dependent on provider preference and situational context. This study was performed to evaluate the effect of length of wire fixation on clinical outcomes after hammertoe reconstruction. Methods: A retrospective review of all hammertoe reconstructions by a single fellowship trained foot and ankle surgeon from 2017-2021 was performed. Hammertoe reconstructions involved PIP arthrodesis with double wire fixation and other supplemental balancing procedures as indicated. Pins were routinely removed at between 5-6 weeks and protected heel weightbearing was generally advised. Wire length was chosen at the discretion of the surgeon intraoperatively. Patients were excluded if no radiographic follow-up was available after pin removal. Patient outcomes were evaluated with radiographs and clinic notes to assess pin length, pin complications/breakage, return to the OR, MTP congruency, and PIP union rate. A logistic regression was performed to determine the odds ratio for digit congruency and non-union status. Results: 88 toes (45 patients) underwent hammertoe reconstruction with K wire fixation. Of these toes, 47 had wires that spanned the MTP and 41 that did not. There were 65 congruent MTP joints and 23 incongruent joints. 16 of the incongruent joints were pinned across the MTP while 31 in the congruent group were pinned. One toe in the MTP group required return to the OR for removal of a broken wire, compared to zero in the phalanx group (p=1.0). No pins broke in the phalanx group, compared to 3 in the MTP group (p=0.25). One toe in the proximal phalanx group had their pins pull out early but no return to the OR was needed. There were 26 (63.4%) PIP radiographic nonunions, compared to 21 (44.7%) in the MTP group (p=0.12). Conclusion: Wire failure was a rare occurrence in either group. Breakage only occurred in the MTP group, but only required one surgical intervention for removal. Pinning the MTP may allow for improved deformity correction and increased stability of the hammertoe reconstruction. Pin breakage can occur, but it may be of little clinical significance. The increased stability and control of MTP correction may be worth the potential risk of pin breakage. Pin breakage may be avoided potentially by using thicker wires, earlier removal, and protected weightbearing.

Category: Midfoot/Forefoot Introduction/Purpose: Arthrodesis of the first metatarsophalangeal (MTP) joint is a well established procedure with excellent outcomes for patients with forefoot disorders including hallux rigidus and hallux valgus Routine bone grafting is not typically required, but bone graft may be necessary in the setting of revision surgery, non-union, or erosive bone loss to encourage biologic fusion and fill bone voids. Options for bone graft include either allograft or autograft. Typical locations for autograft harvesting would include calcaneus, distal tibia, or iliac crest. Due to potential harvesting morbidity and time associated with an extra incision, allograft bone is frequently utilized. In this study, we describe the outcomes of an approach to first MTP fusion with simultaneous medial sesamoidectomy with morselizing the bone for utilization as autograft. Methods: A retrospective review of all first MTP arthrodesis cases performed by one fellowship-trained foot and ankle surgeon were identified. Operative reports and radiographs were reviewed identifying patients that underwent simultaneous medial sesamoidectomy for autograft purposes. Routine bone graft was not typically used for primary first MTP fusion. In the setting of nonunion surgery, revisions, or bone loss, autograft bone was harvested as needed to facilitate fusion. Medial sesamoidectomy was performed via the same dorsal approach without use of an additional incision. The bone was morselized and used to fill voids within the first MTP as needed. Supplemental calcaneal autograft was harvested if the harvest was not adequate (i.e. substantial bone voids). Indications for sesamoidectomy harvesting were noted. The primary outcome reviewed was fusion rate. Overall nonunion rates and patient outcomes were collected and compared between those undergoing sesamoidectomy for grafting and those undergoing standard procedure arthrodesis. Results: During the study period, 74 patients underwent first MTP arthrodesis. Of these, 20 underwent concurrent sesamoidectomy grafting with 11 requiring additional calcaneal grafting. Of the 20, 16 had prior surgeries and 4 had extensive erosive arthritis requiring grafting. Indications for the sesamoidectomy group included 5 primary cases of erosive hallux rigidus, 2 cases of hallux valgus, 3 nonunions, 3 failed Cartiva implants, 2 cases of avascular necrosis, 3 failed arthroplasties, 1 conversion bunionectomy, and 1 conversion from Keller procedure (Table 1). All 20 patients went on to successful union. In the non- sesamoidectomy group the fusion rate was 92.6% (p=0.57). All patients in the sesamoidectomy group were satisfied with their surgical outcome, and no revisions were required. Conclusion: This study found highly successful fusion rates in a potentially higher risk population (i.e. bone loss and revision cases) with the use of local autografting from the medial sesamoid. The medial sesamoid serves as a cost-effective, freely-available, successful graft material for first MTP arthrodesis that can be done quickly via the same incision, reducing potential need for other painful donor sites and the cost associated with allograft. This technique can be particularly useful in the context of revision arthrodesis, failed implants with conversion to arthrodesis, and in arthrodesis with osteoporotic bone or cases with significant erosive arthritis.

Objective: To evaluate the reliability of grading subtalar (ST) arthrosis on lateral weightbearing radiographs in a heterogenous patient population using the Kellgren-Lawrence (KL) scale, correlate these findings to advanced imaging (CT and/or MRI), and to validate a novel scale. Materials and methods: A random collection of 40 lateral weightbearing radiographs presenting to a foot and ankle clinic were reviewed by nine multi-disciplinary independent reviewers. Interobserver reliability was assessed for KL scores. A musculoskeletal radiologist graded available advanced imaging on all 40 radiographs and the advanced imaging scores were correlated to the radiographic scores. A novel scoring system was created and tested for interobserver reliability. Results: There was overall fair reliability amongst reviewers with the traditional KL score, kappa = 0.26. The best agreement was seen amongst those deemed to have a grade 0, with only moderate agreement (k = 0.50). There was only fair interobserver reliability with severe, Grade 4 scores (k = 0.28). Radiographic scores did have moderate correlation with advanced imaging (r = 0.56). A new, simple grading system was proposed and its interobserver reliability was improved substantially (kappa = 0.68). Conclusions: The KL scoring system is not applicable to the subtalar joint. The new NSS grading system has improved reliability. Radiographs only had moderate correlation to advanced imaging. Further studies are warranted to correlate clinically.