Twelve patients (15 feet) with severe hallux rigidus underwent distally based capsule-periosteum interpositional arthroplasty of the first metatarsophalangeal joint (mean ± SD follow-up, 16.8 ± 7.0 months). Subjective evaluation was based on a modified version of the American Orthopaedic Foot and Ankle Society’s 100-point Hallux Metatarsophalangeal-Interphalangeal Joint Scale. Objective evaluation consisted of preoperative and postoperative physical examinations (first metatarsophalangeal joint range of motion and axial grind testing) and radiographic evaluations (joint space width). The short-term results of this novel procedure showed subjective patient improvement and satisfaction, increased first metatarsophalangeal joint dorsal range of motion, maintained hallux plantar range of motion and power, and improved joint space width on anteroposterior and lateral radiographs. None of the patients developed a hallux hammer toe or extensus deformity or lesser metatarsalgia, and none required further surgical intervention. After describing the indications of the procedure and the surgical technique, the authors compare the results with those of the various other procedures available for the surgical treatment of hallux rigidus. (J Am Podiatr Med Assoc 93(5): 349-366, 2003)

Forty-four patients (47 feet) underwent surgical intervention for symptomatic hallux rigidus between February 1998 and April 1999. Each foot was initially graded according to a four-stage hybrid hallux rigidus radiographic grading system. A subjective evaluation based on a modified American Orthopaedic Foot and Ankle Surgery clinical rating system was performed. An objective physical examination was performed. Angular and linear measurements were obtained from standard weightbearing radiographs. The extent of articular derangement for the first metatarsal head, base of the proximal phalanx, and tibial and fibular sesamoids were graded according to the American Orthopaedic Foot and Ankle Society intraoperative grading system. Finally, a means of quantifying the percentage of first metatarsal head articular derangement was performed. Significant differences were identified between joints radiographically classified as grade II, which had lower nonweightbearing, relaxed hanging position (p = .041); nonweightbearing assisted dorsiflexion (p = .000); actual nonweightbearing dorsal range of motion (p = .002); and actual plantar range of motion (p = .009) than those classified as grade I. The angle of deviation of the second metatarsophalangeal joint revealed a significant increase in degree of medial angulation as the grade increased (p = .000). None of the remaining radiographic measurements were significant. A correlation between the hybrid radiographic grading system and percentage of actual intraoperative articular derangement was shown to exist.

Forty-seven patients (50 feet) underwent surgical intervention for symptomatic hallux rigidus between February 1998 and April 1999. Thirty-eight patients (41 feet) returned at 1 year for follow-up evaluation. Each foot was graded according to a four-stage hybrid radiographic grading system. At 1-year follow-up, 10 patients were classified as grade I, 17 as grade II, 12 as grade III, and 2 as grade IV. Subjective evaluation was based on a modified American Orthopaedic Foot and Ankle Surgery hallux metatarsophalangeal-interphalangeal 100-point scale. A pre- and postoperative objective physical examination and radiographic analysis were performed. Statistically significant differences between preoperative and postoperative values were found to exist for each portion of the subjective evaluation (p = .000); nonweightbearing dorsiflexion (p = .001); simulated weightbearing dorsiflexion (p = .003); metatarsal protrusion distance and angle of deviation of the second metatarsophalangeal joint (p = .000); and talar-first metatarsal angle (p = .015). For this specific patient population, the short-term results of surgical intervention for hallux rigidus provided subjective patient improvement and satisfaction, as well as a statistically significant but functionally minimal increase in first metatarsophalangeal joint dorsal range of motion. Additionally, in the 19 patients who underwent a periarticular decompression osteotomy, the intended correlation of plantar transposition of the capital fragment and offsetting the longitudinal shortening of the first metatarsal did not exist.

The long Z-osteotomy (scarf) has proven to be an effective procedure for correction of the metatarsus primus varus component of the hallux abducto valgus deformity. An historical review and technical considerations of the procedure are described. Although technically demanding, it offers the advantages of superior strength with internal fixation, early range of motion, and early weightbearing. An uncommon but challenging intraoperative complication of the procedure is troughing (channeling). The author describes a technique that involves transfer of the adductor hallucis tendon through the horizontal aspect of the osteotomy when troughing is encountered. The benefits and potential complications are discussed. Although it occurs infrequently, this new modification has the potential to salvage a potentially debilitating complication.

Lesser interphalangeal and metatarsophalangeal sagittal plane deformities are common pedal pathologies. The mechanical imbalances responsible for the development of these digital deformities have received much attention (1-3), but a complete discussion of these is beyond the scope of this article. In general, when conservative measures have failed to provide long-term satisfactory relief from symptomotology, surgical intervention is undertaken. To this end, a myriad of soft-tissue and osseous procedures have been advocated (4-6). The senior author (lB.R.) utilizes a 60° angled Opthamology #66 mini-bladef (Fig. 1) in the following manner to surgically release the tendinous, capsular, and ligamentous metatarsophalangeal joint contracture component of the digital deformity. A standard longitudinal incision is performed extending from the base of the proximal phalanx to the head of the intermediate phalanx, and deepened to the extensor tendon complex at the level of the proximal interphalangeal joint (Fig. 2). The extensor tendon complex is then incised transversely at this level, with care taken to leave the medial and lateral collateral ligaments intact at the level of the proximal interphalangeal joint. Following this, the medial and lateral margins of the sling and wing components of the extensor digitorum longus tendon are incised vertically, parallel to the longitudinal axis of the proximal phalanx. The resultant extensor digitorum longus tendon flap is then grasped with atraumatic forceps and underscored through a combination of sharp and blunt dissection to the level of the corresponding metatarsal head

The recent development of small bone suture anchors has created several potential applications in reconstructive surgery of the foot. Mitek bone anchors are simple to insert, require less aggressive dissection and surgical time than reefing of the redundant posterior tibial tendon, and are a reliable method of tendon-to-bone fixation. Mitek bone anchors are an excellent technique for the treatment of redundant tibialis posterior tendon following a modified Kidner procedure. In modified Kidner procedures involving an excessively large os tibiale externum, Mitek anchoring of the redundant tibialis posterior tendon to the navicular bone is an excellent means for secure plication of the posterior tibial tendon in cases involving intraoperative tendon laxity. A description of the Mitek Anchor System and technique of application in a modified Kinder procedure is presented. The purpose of this study was to describe patient satisfaction and long-term clinical outcomes of the modified Kinder procedure with and without the Mitek bone anchoring system. A retrospective study of the modified Kinder procedure was performed with 13 patients being evaluated, seven with Mitek anchoring and six without. The University of Maryland 100-point Painful Foot Center Scoring System was modified to be more specific to the modified Kinder procedure for assessment of subjective long-term results. Patient overall satisfaction was rated good to excellent by 85.6% of patients in the Mitek group and by 100% of patients in the non-Mitek group. Use of the Mitek anchor allowed for quicker postoperative recovery to resumption of ambulation without assistive devices (average of 3 weeks vs. 4.42 weeks) and a quicker return to pain-free ambulation in normal shoegear (average of 4 weeks vs. 6 weeks). Mitek anchoring of the tibialis posterior tendon, theoretically, increases medial arch support as evidenced by 14% of the Mitek group and 67% of the non-Mitek group requiring postoperative orthotics.

Foot pain is a most unusual presentation of metastatic malignancy. Metastases to the hands or feet (acrometastases) have been recognized in only a few cases. A 68-year-old male, with a history of chronic gout, presented with left foot pain for 3 months duration. After conservative treatment failed to relieve his pain, radiographic and eventual bone biopsy of a cystic lesion involving the first metatarsal head revealed a Grade IV adenocarcinoma.