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A case of osteoid osteoma of proximal phalanx of second toe is presented. The clinical, radiological, and pathological features are discussed. Osteoid osteoma is rare in toe phalanges but should be considered when a patient presents with unexplained chronic pain in his or her toes.
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In order to understand the function of toes during free walking, movements of the toes of 30 normal adults were measured with the electrogoniometers. The angular changes of the interphalangeal (IP) joint of the 1st toe and the distal interphalangeal (DIP) joints of the 2nd to 4th toes, the ground reaction force, foot switch signal and the pressure changes in the forefoot were recorded simultaneously. The relationships between these measurements were then investigated. During the foot-flat phase, the IP joint of the 1st toe stayed at a flexed position, while the DIP joints of the 2nd to 4th toes remained at a slightly extended or neutral position but there was scarcely any pressure on the toe tips (0-0.3 kg/cm3). After the heel-off, the pressure on the 1st toe tip gained with increasing flexion of the IP joint of the 1st toe. The mean of the maximum angles was 13 +/- 5 (mean +/- SD) degrees. After the heel-off, the DIP joints of the 2nd and 3rd toes remained in the extended position in 16 cases (6.6 +/- 3.1 and 6.3 +/- 3.4 degrees) and appeared to stay at a flexed position in 14 cases (10.0 +/- 7.8 and 8.0 +/- 5.3 degrees). The DIP joint of the 4th toe remained in the extended position in all cases (9.2 +/- 8.5 degrees). The pressure of the toe tips increased. The magnitude of the pressure of the extended toe tips was higher than that in the flexed toe tips. The pressure of the toe tips of the 1st to 4th toes reached the maximum much earlier than that of the toe-off. From these observations, we conclude that the function of the toes during free walking seems to stabilize the foot by extending a contact area with floor mainly after the heel-off.
Excessive great toe length may be attributed to an unusually long first metatarsal, proximal phalanx, distal phalanx, or a combination of two or all three components. The procedure proposed here is not recommended for deformity existing in conjunction with a long first metatarsal or a pathologic first metatarsophalangeal joint. It has been used in mild to moderate hallux abductus or abductovalgus associated with intact first metatarsophalangeal joint cartilage and a long great toe.
The outcome of surgically treated mucous cysts of the foot is poorly documented in the orthopaedic literature. This study reports on the treatment of mucous cysts of the toes by simple excision and joint debridement. This is in contrast to treatment of similar lesions in the fingers which is often treated by excision of the cyst, joint debridement, and rotational flap. Following this procedure on 15 patients (15 cysts), at a minimum of 2 years postoperatively, only one cyst had recurred at 9 months. All patients were satisfied by the cosmetic appearance of their toe. The authors reviewed the available literature on this condition and suggest that this method of treatment provides good functional and cosmetic results with a minimal rate of recurrence.
Two patients with a deviated overlapping second toe due to rupture of the dorsal lateral metatarsophalangeal (MTP) collateral ligament and the lateral interosseous tendon were diagnosed, analyzed, and treated. Athletic activities were responsible for the tendon-ligament ruptures and the ensuing medial deviation of the second toe. Pain occurred in the second MTP joint, and a dorsal corn formed over the proximal interphalangeal joint (PIP). Reconstructive procedures included lengthening of the interosseous-lumbrical tendons and the collateral ligament on the medial side of the joint; a dorsal capsule incision; repair of the lateral collateral ligament and interosseous tendon; transfer of the flexor digitorum longus to the extensor digitorum longus; and shortening of the proximal phalanx in one patient. These soft tissue reconstructive procedures and realignment joint congruity are essential to relieve pain and prevent traumatic arthrosis. The treatment completed on the two patients resulted in relief of pain, satisfactory function, and alignment of the digits involved.
In vitro contact pressures were measured at the first metatarsocuneiform joint in order to determine the effect of resectional arthroplasty and arthrodesis of the metatarsophalangeal joint of the great toe. Eight fresh cadaver feet were loaded with the Instron machine to determine the pressure seen at the first metatarsocuneiform joint. The specimens were subsequently modified by performing either an arthrodesis of the great toe metatarsophalangeal joint or an arthroplasty of this joint by removal of the proximal one third of the proximal phalanx. A second test was then performed. Pressure-sensitive film was analyzed to determine maximum pressure and total transmitted force. No significant pressure change was seen after the arthrodesis. After the resection arthroplasty, there was a significant decrease in both the maximum pressure and the total force measured at the first metatarsocuneiform joint.
Over a 14-year period, 60 patients (86 toes) underwent resection arthroplasty of the proximal interphalangeal joint for a mallet toe deformity. During the same period, 788 hammertoe corrections were performed, for a ratio of 9:1 hammertoe to mallet toe corrections. Fifty patients (72 toes) were evaluated at an average 55-month follow-up. In 53 toes (73%), the involved toe was longer than the adjacent toes. The second, third, and fourth toes were almost equally involved with a mallet toe deformity. With a resection arthroplasty technique, an arthrodesis of the PIP joint occurred in 52 toes (72%) and a fibrous union occurred in the remaining 20 toes (28%). Overall, 86% of the toes were rated as satisfactory by the patient (P < .001). A slightly lower satisfaction rate (75%) was noted in those toes with a fibrous union. A flexor tenotomy was performed in 22 toes along with the mallet toe repair. Acceptable alignment was noted in 96% of toes with a flexor tenotomy, and in 90% where a mallet toe repair was performed without a flexor tenotomy [corrected]. Pain was relieved (97%), correction was well maintained (91%), and patient subjective satisfaction was high (86%) with this procedure. Minor complications occurred in 14% of cases; however, one fourth of these patients still noted a satisfactory result.
Eighty-six lesser toe basal hemiphalangectomies were performed in 52 patients. The surgical technique included an oblique dorsal incision, resection of 8 mm of bone, and an extensor tenotomy. Minimum follow-up was 2 years (range 2-6/1/2 years). Sixty percent of the patients had total relief of pain. Twenty-nine percent stated that they would not have the surgery again, and we categorized these patients as dissatisfied. An extensor tenotomy increased the satisfaction rate and was found to decrease the radiographic sagittal angulation of the toe. The preoperative diagnosis was significant to the outcome of the surgery. Patients with metatarsophalangeal joint synovitis and rheumatoid toe deformities had high rates of satisfaction; those with transverse deviation, metatarsalgia, and hammertoes with metatarsophalangeal joint subluxation/dislocation had lower rates of satisfaction. Seventy percent of the dissatisfied patients were dissatisfied because of persistent flexion deformity of the PIP joint or pain under the metatarsal head. We now add a PIP fusion if any flexion deformity, even a mild deformity, is present at the PIP joint and a plantar metatarsal condylectomy for metatarsalgia.
One hundred ten diabetic foot infections were studied in 76 patients with reference to the effect of the anatomic location of the infection on the treatment outcome. Distal infections were located in the toes or metatarsal-phalangeal joints; proximal infections were located along metatarsals, at the heel, or above the ankle. Overall limb salvage was significantly lower in the proximal group (47.8%) than in the distal group (96.6%). A revascularization for healing was required in 12 per cent of hospitalizations. Mortality was significantly higher in the proximal group, but the healing times for open wounds and overall morbidity were not different between the groups. Diabetic foot infections must receive careful and timely treatment by concerned surgeons. The outcome of proximal infections is poor, with major risk of limb loss and mortality, but not hopeless. The treatment of distal infections derives greater limb salvage with nevertheless similar morbidity and healing time.
The big toe is of great importance for good stability and gait, but few reports have documented reconstruction of big toe defects. In this study, seven male patients, aged 17 to 59 years at surgery (average: 35 years), were treated for big toe defects. The metatarsophalangeal (MTP) joints of the big toe were intact in all patients. Five patients were treated with free peroneal flaps (including one perforator flap), and two with free scapular flaps; flap sizes ranged from 9 x 4 to 24 x 6 cm. Follow-up periods ranged from 10 to 29 months, (average: 16.6 months). The iliac was used as the grafted bone in four patients and the scapula in one. Six flaps survived completely, and bone unions were achieved within 3 months. One flap became partially necrotic due to arterial thrombosis. All patients returned to their original jobs, and the cosmetic appearances of all toes were acceptable.
The incidence and ossification of sesamoid bones in the hands and feet were studied in 922 radiographs (400 hands and 522 feet) in an Arab population from Bahrain, 5-83 years of age and consisting of 549 adults (393 men and 156 women) and 373 children (286 boys and 97 girls). All radiographs of the hand and foot in the adult population showed two sesamoid bones in the thumb metacarpophalangeal (MCP) joint and in the hallucal metatarsophalangeal (MTP) joint, respectively. Only 2.3% and 1.5% of hands showed sesamoids at the MCP joints of the middle and ring fingers respectively compared to a reported incidence of 7.1% for each digit in Caucasians. The incidence of sesamoids in the MTP joints of third and fourth toes (0.6% each) and inferior to the hallucal interphalangeal joint (3.1%) is probably the lowest reported so far in the literature. In the hands, ossification commenced first in the thumb sesamoids, at the age of 10 years in females and 11 years in males and was completed by the age of 13 and 14 years, respectively. In the feet, ossification began first in the hallucal sesamoids at the age of 8 years in females and 9 years in males and was completed by the age of 10 years in both sexes. The incidence and ossification of sesamoids in the hands and feet in the Arab population from Bahrain seem to differ considerably from reports in other populations. The clinical significance of our findings is discussed.
Irreducible dislocation of an interphalangeal (IP) joint of the great toe is a rare condition. Twenty-two cases including the present two cases are reported in available literature. Two different types are identifiable. In one type, where the ruptured volar plate is displaced into the joint space between two phalanges, the toe is slightly elongated, but the deformity of the toe is not so marked. In the other type, where the volar plate is completely displaced over the proximal phalangeal neck, the deformity of the toe is extreme as the IP joint is locked in hyperextension. In the former type, the dislocation is often misinterpreted to have been repositioned manually because of relatively slight deformity. In either type of dislocation, the volar plate is detached from both the distal and proximal phalanges, and so displaced into the joint, as to form a barrier to manual repositioning. Open reduction is mandatory.
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BACKGROUND: The main bony procedures used in the treatment of second hammertoe are excisional arthroplasty and arthrodesis of the proximal interphalangeal (PIP) joint. While a number of studies have reported the outcomes after PIP joint arthrodesis, there are few reports of the outcome of excisional arthroplasty of the PIP joint for the correction of second hammertoes. The purpose of this study was to evaluate the long-term outcome of PIP joint excisional arthroplasty. METHODS: Seventy-five patients (100 toes) who had excisional arthroplasty of the PIP joint for the correction of second hammertoe were reviewed at an average followup of 44 months. All patients were seen in clinic and were physically examined to assess the alignment and function of each digit. The radiographs were evaluated preoperatively. The AOFAS clinical rating scale was used preoperatively and at final followup. Patients were asked to rate their satisfaction on a scale of 0 to 10 and were asked if they would be happy to have the surgery under similar circumstances again. RESULTS: The mean preoperative AOFAS clinical rating scale was 46. At final followup this increased to 94, showing an average improvement of 48 points (p < 0.0001). The mean satisfaction on a scale of 0 to 10 (with 0 equaling complete dissatisfaction and 10 complete satisfaction) was 9.3 (SD 1.3). One patient would not have been happy to undergo outpatient surgery again, because of a change in her social circumstances. CONCLUSION: In a group of 75 patients who had PIP joint arthroplasty for the correction of second hammertoe, high levels of satisfaction were achieved. No serious complications were encountered, and revision surgery was required in just two cases. Floating toe was the most common complication encountered, and although this did decrease the level of patient satisfaction in seven patients it was not a cause of footwear irritation or pain in any patient.
Various foot structures are thought to influence forefoot plantar pressures during walking. High peak plantar pressures (PPP) during walking in people with diabetes mellitus (DM) and peripheral neuropathy (PN) can cause skin breakdown. The question addressed by this study is "What are the primary forefoot structural factors that predict regional PPP during walking in groups of people with and without DM and PN?" Twenty people with DM and PN (mean age 55+/-9 years, 6 female, 14 male, BMI=33+/-8) and 20 people without DM, matched for gender, age, and BMI were tested. Measures of foot structure were taken from three-dimensional images constructed from spiral X-ray computed tomography. Peak plantar pressure data were recorded during walking. Hierarchical multiple regression analysis was used to predict regional PPP at the great toe and five metatarsal heads from selected structural and walking variables. Metatarsal phalangeal joint angle (hammer toe deformity) was the most important variable predicting pressure, accounting for 19-45% of the PPP variance at five of the six locations in the DM group. Soft tissue thickness, hallux valgus, and forefoot arthropathy were the most important predictors of PPP in the control group. Combinations of structural and walking variables accounted for 47-71% of the variance in the DM group and 52-83% of the variance of PPP during walking in the control group. These structural variables, especially hammer toe deformity, should be considered in attempts to develop strategies to reduce excessive forefoot PPP that may contribute to skin breakdown or other injury.
The spoon-toe hallux deformity causing symptomatic hallux pathology can be corrected through a minimal incision stab tenotomy of the extensor hallucis longus tendon that is usually performed at the level of the interphalangeal joint. This procedure is recommended rather than a traditional tenoplasty because it creates very little disability, successfully reduces the deformity, has low incidence of complications, and produces lasting results in maintaining the correction. The procedure can be used as both a solo procedure or in conjunction with other procedures on the hallux.