Search

Background and Objective: The dorsal osteophyte on the distal phalanx of the first toe (hallux) is a reactive bony protrusion that may be associated with pathologies such as onychocryptosis or pincer nail. This study aims to describe and analyze the correlation between three novel measurements-dorsal osteophyte height (HDO), distal phalangeal hyperextension (DPHA), and distal phalangeal curvature (DCDP)-and to evaluate the impact of minimally invasive surgery on the dorsal osteophyte using fluoroscopic data. Materials and Methods: A total of 125 fluoroscopic images were analyzed. Baseline measurements for the variables were compared between groups. The key variables included distal phalanx curvature, distal phalanx hyperextension, and dorsal osteophyte height. Results: The analysis revealed statistically significant differences in the main group effect for distal phalanx curvature (F [2, 122] = 7.54, p < 0.001), distal phalanx hyperextension (F [2, 122] = 28.90, p < 0.001), and dorsal osteophyte height (F [2, 122] = 13.64, p < 0.001). Significant correlations were found between distal phalanx curvature and distal phalanx hyperextension, as well as between distal phalanx hyperextension and dorsal osteophyte height. However, no significant correlation was observed between distal phalanx curvature and dorsal osteophyte height. Conclusions : The findings suggest that minimally invasive dorsal osteophyte surgery effectively restores the distal phalanx to normal conditions, as indicated by the variables studied.

Hallux amputations have long been performed for the definitive treatment of hallux osteomyelitis resulting from ulcerations. These amputations have been performed at various levels of the hallux. The aim of this study is to assess the long-term outcomes in patients with hallux amputations performed at these various levels and to determine whether there is an ideal anatomic level that would limit post-operative complications and need for revisional surgery. An Institutional Review Board (IRB)-approved retrospective chart review of 148 feet with hallux amputations performed at various levels from July 1, 2013 to July 16, 2020 at an academic medical center was conducted. A 2-year minimum follow up was required for inclusion in the study. Incidence of re-ulceration, need for further amputation, healing of index procedure, and revascularization status were evaluated. Statistical analysis utilizing chi square analysis was performed to calculate p-values where <.05 was statistically significant. In this retrospective study with a minimum of 2-year follow-up, there was a tendency for amputations performed at the level of the head of the proximal phalanx (21%) to have a lower rate of reulceration (24%) followed by amputations performed at the level of the metatarsophalangeal joint and interphalangeal joints (36%). However, neither proved to be statistically significant., (Copyright © 2024 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Reconstruction of hallux soft-tissue defects is essential for the locomotor function. Some regional flaps are available and have to be preferred in case of small defect. Here, we present the case of a patient treated by a cross-toe flap in order to cover an exposed hallux proximal interphalangeal joint, after an open fracture. The functional outcome of this reliable and easy flap was very satisfying, with quick wound healing and resumption walk., (Copyright © 2023 Elsevier Masson SAS. All rights reserved.)

Background: We sought to determine the rates of reulceration and reamputation in individuals who underwent partial first-ray amputations versus hallux amputations in diabetic and nondiabetic populations., Methods: Eighty-four amputations were reviewed in a retrospective fashion. A retrospective medical record review was performed to determine patients who underwent a hallux amputation, both partial and complete, and patients who underwent a partial first-ray amputation. Only patients from 2007 to 2019 were reviewed. The reulceration rate of hallux amputations was 61% compared with a partial first-ray amputation reulceration rate of 74%., Results: The reamputation rate of hallux amputation versus partial first-ray amputation was 43% versus 51%. At final follow-up, it was statistically significant that patients who underwent hallux amputation were more likely to be healed than those who underwent partial first-ray amputation, regardless of reulceration or reamputation. In addition, patients who underwent hallux amputation went on to digital amputation, and those who underwent partial first-ray amputation went on to transmetatarsal amputation., Conclusions: Comparing partial first-ray amputation to hallux amputation, hallux amputation patients are more prone to subsequent digital ulceration. Patients who initially undergo hallux amputation have variable subsequent amputations, often digital. Reulceration primarily occurs at the incision site for partial first-ray amputations, with a higher likelihood of subsequent transmetatarsal amputation. Patients with a medical history of diabetes and staged procedures are more likely to receive partial first-ray amputations. However, hallux amputation patients have a lower risk of reulceration and reamputation, regardless of subsequent events. These findings underscore the importance of discussing risks and preventive measures with patients undergoing such amputations, emphasizing postoperative examinations for specific areas of concern. Hallux amputation appears to offer greater protection against reulceration and reamputation for both diabetic and nondiabetic populations.

Objectives: The purposes of this study were to examine indications, radiographic outcomes, and clinical complications for primary arthrodesis of the great toe interphalangeal (IP) joint in young patients., Background: Hallux valgus interphalangeus deformity of the great toe is uncommon in the pediatric population and often requires fusion of the IP joint., Methods: A retrospective review of patients, ages 8 to 19 years, who underwent operative fusion of the great toe IP joint, and had >1 year radiographic follow-up was performed. Medical records and radiographs were reviewed to determine indications for surgery, concomitant procedures, success of fusion, complications, and need for revision procedures or elective hardware removal. Differences between pre and postradiographic outcomes for the hallux valgus angle, IP angle, and intermetatarsal angle were analyzed., Results: Twenty-seven patients (31 feet) were included in the analyses. The average age at fusion surgery was 14.9 years (SD ± 2.3) with a mean follow-up visit of 35.2 months. The most common indications for fusion of the great toe IP joint were pain and deformity. Kirschner wire fixation was utilized in 7 cases, with the remaining 24 cases fixed with a single retrograde cannulated screw. Fifty-five concomitant toe and foot procedures were performed in 21 feet (68%) to address additional foot and toe deformity. Successful fusion occurred in 30 of 31 toes after the primary fusion. Patient satisfaction with the toe position and diminished pain were high (94.1%). Significant improvement was noted in the measure of the IP angle ( P < 0.001), with minimal clinical change in the hallux valgus angle ( P = 0.24) or the intermetatarsal angle ( P = 0.03)., Conclusions: Hallux valgus interphalangeus of the great toe was successfully managed with the fusion of the IP joint. Single screw fixation or the use of Kirschner wires led to similar outcomes. Hardware-related issues with the use of screws were the most common adverse outcome. Patients should be made aware of the possible need for hardware removal after fusion utilizing screw fixation., Level of Evidence: Level IV-a retrospective case series., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

A frontal plane metatarsal rotational (pronation) has been documented in a high percentage of hallux valgus patients. Pathoanatomical concepts leading to pronation are still debated. Nevertheless, there is no consensus on how to measure this component of the deformity. The aim of the present study was to find potential associations between sesamoid's crista osteoarthritis and the frontal plane deformity in HV cases. Our study showed a moderate correlation between the crista's OA and the intermetatarsal angle (IMA), the hallux valgus angle (HVA) and the alpha angle. In severe hallux vulgus deformed specimens, with an eroded intersesamoid crista, frontal plane pronation was not as prevalent nor severe as in those without osteoarthritic degeneration. Severe hallux valgus cases with a completely eroded crista, showed lower pronation, and higher IMA, when compared to specimens with a preserved anatomy. This brings to light the intersesamoid crista's unique function in retaining the IMA. Understanding the role the frontal plane plays in hallux valgus' biomechanics and in its radiographic appearance is vital to change the current paradigm., (Copyright © 2023 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

The claw toe deformity is characterized by the flexion of interphalangeal joints (IPJs) with hyperextension of the metatarsophalangeal (MTP) joint. It can be flexible and reducible or rigid and irreducible, or dynamic. The most common cause of dynamic claw toes is a neurological disorder, like sequelae of an ischemic contracture of the muscle belly after a compartment syndrome. Most of the surgical techniques require multiple procedures and may be associated with complications such as toe stiffness, persisting metatarsalgia, and toe malalignment. The aim of this study is to present an option for the surgical treatment of the dynamic claw toe deformity, by simultaneous tenodesis and lengthening of the flexor hallucis longus (FHL) and flexor digitorum longus (FDL) tendons at Henry's knot through a single midfoot incision.Levels of Evidence: V; Therapeutic Study; Expert Opinion ., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Hallux extensus is a persistent dorsiflexion of the first metatarsophalangeal joint. Apart from many other causes, it can also be caused by contracture of the extensor hallucis longus muscle, in our case resulting from surgical treatment of crural fracture. The authors present the case of a 17-year-old soccer player who sustained a fracture of both shin and calf bone during a soccer match and underwent surgical treatment with intramedullary nailing. While compartment syndrome wasn't observed, a postoperative complication in the form of progressive development of a dynamic type of hallux extensus was reported. The reason behind this complication was later found to be the interaction of the osteosynthesis material with the extensor hallucis longus muscle, which led to its scarring and shortening. A Z-lengthening of the musculus extensor hallucis longus tendon was indicated and performed with a good clinical outcome. During surgery, an anatomical variation in the course of the extensor hallucis longus was observed, which had to be taken into account to achieve a successful surgical outcome. Key words: cock-up big toe deformity, musculus extensor hallucis longus contracture, Z-lengthening tenotomy, crural fracture complication.

Background: Historically, the degloved finger with the total loss of nails and skin has been resurfaced in two stages. Furthermore, proximal finger amputation requires an additional bone-tendon graft and an expanded great toe wraparound flap transfer for better outcomes. This article recommends a novel strategy to address these problems in a single stage using a dorsal nail-skin flap and medial plantar artery perforator flap., Methods: From March of 2015 to June of 2018, nine procedures were performed to resurface with skin loss to the metacarpophalangeal joint level, and three amputated fingers were reconstructed with an extra bone-joint-tendon graft simultaneously. The dorsal great toe donor was covered with a thin groin flap, and the medial plantar site was covered with a full-thickness skin graft. A standardized assessment of outcome in terms of sensory, functional, and aesthetic performance was completed., Results: All flaps survived. The contour and length of the reconstructed digits were comparable with the contralateral finger. The mean static two-point discrimination was 11.0 mm (range, 9.0 to 14.0 mm). The average score of the Disabilities of the Arm, Shoulder, and Hand questionnaire and Michigan Hand Outcomes Questionnaire were 2.5 (range, 0 to 5) and 90.1 (range, 82 to 96), respectively. The mean Foot and Ankle Disability Index score was 95.6 (range, 93 to 99). At the last follow-up, the functional and aesthetic outcomes, and the restored sensation, were satisfactory for all fingers., Conclusion: This strategy may provide an alternative for selected patients seeking cosmetic resurfacing and functional reconstruction, preserving a weight-bearing plantar area with less morbidity., Clinical Question/level of Evidence: Therapeutic, IV., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Case: A motorcycle accident resulted in severe soft tissue loss on the foot's dorsum with irreparable hallucis extensors, with exposure of the first metatarsal and hallux. An arthrodesis of the hallux interphalangeal joint, a transfer of the second toe's extensor digitorum longus, and an anterolateral thigh free flap were performed simultaneously. The patient obtained a fair result and could wear regular shoes., Discussion: This is the first report describing this orthoplastic reconstructive option in these complex injuries. It replenished both hallux extensor tendons and soft tissue coverage losses without severely compromising the foot's contour, recreating anatomy and function., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C258)., (Copyright © 2023 by The Journal of Bone and Joint Surgery, Incorporated.)

BACKGROUND Tarsometatarsal joint (TMJ) arthrodesis is common method used for correcting hallux abductus valgus (HAV). Its popularity has grown due to studies revealing HAV's triplanar deformity with frontal plane rotation. This case report presents a 28-year-old woman with Down syndrome, congenital heart disease, and a history of knee surgery and plantar fasciitis, with severe HAV deformity and flexible valgus flatfoot associated with ligamentous hyperlaxity. CASE REPORT Examination revealed severe foot deformities, and radiographic studies confirmed the condition. A surgical intervention was planned, and the patient's cardiologist confirmed she was fit for the procedure. The modified Lapidus technique with frontal plane rotational correction included realigning the metatarsal joint, resecting spurs, osteosynthesis material, and arthrosis in the sinus tarsi. After surgery, the patient underwent a recovery period without support for 8 weeks and received appropriate medical care. Radiographs showed successful alignment, and the patient gradually resumed her daily activities. The patient had an uneventful recovery, and postoperative radiographs showed good alignment in all planes. CONCLUSIONS The hyperlaxity associated with Down syndrome makes the incidence of HAV more frequent, and TMJ fusion is preferable to correction by osteotomy. The modified Lapidus technique with frontal plane rotational correction could be a good technique to achieve satisfactory correction in patients with severe HAV deformity and flexible valgus flatfoot associated with ligamentous hyperlaxity. TMJ fusion is indicated when severe or recurrent rotational component is observed in X-rays.

Background: Hallux interphalangeal joint arthrodesis (HIPJA) is indicated for a variety of pathologies. Despite high nonunion rates, techniques remain unchanged. The aim of this study is to examine nonunion and complication rates and describe risk factors for treatment failure., Methods: A query of an institutional database was performed to identify all patients undergoing HIPJA procedure over a 10-year period. Records were reviewed to the procedure, evaluate patient factors, indications, and radiographic/clinical arthrodesis. Radiographic union was defined as 2 cortical continuations or bridging at the arthrodesis site, absence of hardware failure, and the absence of lytic gapping of the arthrodesis. Clinical fibrous union was defined as radiographic nonunion with painless toe range of motion and physical examination consistent with fusion across the interphalangeal joint., Results: Two hundred twenty-seven primary HIPJA procedures were identified. Our cohort demonstrated a 25.5% nonunion rate (58/227) and 21.1% reoperation rate (48/227). Patients with diabetes were at higher risk for nonunion ( P = .014), but no significant differences were identified based on smoking status or diagnosis of inflammatory arthritis. No difference was seen between implant groups: single screw, multiple screws, screw plus other fixation, nonscrew fixation. Patients with prior hallux metatarsophalangeal joint arthrodesis did not have a significantly higher nonunion rate than patients without prior first metatarsophalangeal joint arthrodesis. Patients diagnosed with radiographic nonunion were at higher risk for reoperation ( P  < .0001)., Conclusion: Our cohort represents the largest single-center series of HIPJA procedures published to date. We found relatively high nonunion and reoperation rates with standard current techniques., Level of Evidence: Level III, retrospective case series., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. ICMJE forms for all authors are available online.

Background: The purpose of this study was to determine the results of an arthrodesis technique of the first metatarsophalangeal joint (MTPJ) using a precontoured dorsal plate to correct the hallux valgus deformity., Methods: This was a retrospective analysis of outcomes for first MTPJ arthrodesis performed using 2 precontoured dorsal plates. Radiographic outcomes (intermetatarsal angle [IMA] and hallux valgus angle [HVA]) and patient-reported functional outcome measures (Short-Form 12 and Foot and Ankle Outcome Score) were recorded and compared., Results: Fifty-five patients underwent 77 first MTPJ arthrodeses for severe hallux valgus deformity with associated degenerative changes at the first MTPJ. The mean reduction of the IMA was 5.67° ( P < .05) and the mean reduction of the HVA was 33° ( P < .05). The Short-Form 12 assessment of global health demonstrated a significant improvement in both the physical and mental health composite scores by 16.4 points and 10.4 points ( P < .05), respectively. The Foot and Ankle Outcome Score demonstrated a cumulative decrease of 35% (59.28; P < .05) in all domains., Conclusions: First MTPJ arthrodesis using a precontoured dorsal plate is a successful procedure with a high union rate, low complication rate, and a high level of patient-reported satisfaction., Levels of Evidence: Level III ., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Dorsal plate fixation is commonly used for first metatarsophalangeal joint (1st MTPJ) arthrodesis and plate design continues to evolve. A new staple compression plate (SCP) design attempts to utilize the continuous compression of a nitinol staple across the fusion site while simultaneously providing the stability of a dorsal locked plate. Herein, we compare the radiographic, clinical, and patient-reported outcomes of 1st MTPJ joint arthrodesis using 2 dorsal locking plate constructs including a novel SCP construct., Methods: Forty-four patients who underwent 1st MTPJ arthrodesis between 2016 and 2020 were retrospectively evaluated. There were 2 group cohorts. Group 1 cohort included 23 patients who received a CrossRoads Extremity SCP, and Group 2 cohort included 21 patients who received a Stryker dorsal locking precontoured titanium plate (LPP). All patients were evaluated with radiographs, Patient-Reported Outcomes Measures Information System (PROMIS) outcome scores, and Foot Function Index (FFI)., Results: The complication and union rates did not vary between groups with a fusion rate of 95.7% in the SCP group and 90.5 % in the LPP group. Similarly, we found no significant differences in PROMIS or FFI scores between the SCP and LPP plates., Conclusion: Use of either dorsal locking plate construct for 1st MTPJ arthrodesis was associated with high union rates and comparable functional outcomes. As locked plate technology continues to evolve for 1st MTPJ arthrodesis, it is important that clinical outcomes are reported., Levels of Evidence: Level IV., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Ashish Shah is a paid consultant for CrossRoads Extremity Systems. No other author benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

Purpose: Recently first tarsometatarsal arthrodesis for hallux abducto valgus (HAV) has been advocated as the sole procedure to correct the multiplanar components of the deformity. However, recent debate suggests other factors such as rearfoot pronation and metatarsal torsion affect frontal plane metatarsal eversion and sesamoid positioning. Using weight-bearing CT, 12 feet (12 subjects) with HAV deformities were placed in positions of maximum rearfoot pronation and supination in order to study the effects on metatarsal eversion, sesamoid rotation/displacement, and secondarily the influence of first metatarsal torsion. Sesamoid displacement was quantified by the novel use of the sesamoid displacement angle., Principle Results: Although first metatarsal eversion was nearly double in the pronated versus supinated foot, the difference was not statistically significant. Therefore, the bulk of first metatarsal eversion was not secondary to rearfoot eversion. Conversely, a significant positive correlation was found between metatarsal torsion and metatarsal head eversion angles in both supinated and pronated foot positions, with the strongest correlation with rearfoot pronation. Finally, significant increases in sesamoid displacement angles were noted with pronation., Major Conclusions: The findings of the present study support the contention that multiple factors are associated with frontal plane first metatarsal eversion and sesamoid displacement. Weight-bearing CT scanning can be used to effectively evaluate the frontal plane components in HAV deformities. The sesamoid displacement angle appears to be a useful adjunct to evaluating the hallucal sesamoids. For surgical correction of the deformity, consideration should be given to pre-operative weight-bearing CT evaluation of the foot. This can illuminate the effects of rearfoot/medial column pronation and the potential influence of metatarsal torsion on the frontal plane components of this triplane deformity. In this way the potential for post-operative HAV recurrence can be minimized., Competing Interests: Declarations of Competing Interest None., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background: Plantar hallux IPJ ulcers are common and challenging to manage, with many available treatments. One newer technique called SPFR has been used in the management of plantar forefoot ulcers., Objective: This case series reports the clinical results of SPFR for treatment of strictly plantar hallux IPJ ulcers., Materials and Methods: A retrospective chart review was conducted on patients that underwent SPFR procedure by a single foot and ankle surgeon from 2018 to 2023. The primary study outcome was to identify the rate and time of healing associated with SPFR for hallux IPJ ulcers. Only the initial surgery was evaluated for time of healing for the ulcer, healing rate, and complications. Subsequent surgeries were reviewed as well. Patient charts were further reviewed to determine the presence or absence of a postoperative complication., Results: A total of 17 feet from 17 patients were studied. The hallux IPJ ulcers healed in an average of 3.0 months. The average follow-up time was 26.9 months. Fifteen patients (88.2%) healed after the SPFR procedure. Five patients (29.4%) developed transfer lesions, and 7 patients (41.2%) developed postoperative complications., Conclusions: The authors believe that SPFR can be utilized in the treatment of hallux IPJ ulcers if both surgeons and patients are aware of the potential complications and limitations of this procedure. Further research is warranted to evaluate the efficacy and reproducibility of these results.

We report the results of using a fibula-sided digital artery pedicled flap from the great toe to cover the second toe free flap donor site, which avoids delayed wound healing, and prevents pain and skin ulceration. This study included 15 patients who had second toe wrap-around free flaps to reconstruct thumb and finger defects. All 15 pedicled flaps used to cover the defect healed uneventfully. All patients were able to stand and walk and were satisfied with the postoperative aesthetic outcome at the 6-month follow-up. We conclude that this an effective procedure for preventing donor site defects after second toe wrap-around free flap transfer. Level of evidence: IV., Competing Interests: Declaration of conflicting interestsThe authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The finding of "hypermobility" has conventionally been considered as a dichotomous categorical variable in both clinical practice and in the literature. In other words, it is defined as being either "present" or "absent" in patients with hallux valgus. Yet it might be far more likely that this represents a continuous variable described by a bell-shaped distribution. Therefore the objective of this investigation was to consider hypermobility as a continuous variable, and to compare the sagittal plane first ray motion to radiographic parameters commonly used in the evaluation of the hallux valgus deformity by means of correlation analyses. The radiographs and measurements of 86 feet were included and measurement of sagittal plane first ray motion was performed with the validated Klaue device. No statistically significant correlation was observed between the total first ray motion with the first intermetatarsal angle (Pearson correlation coefficient 0.106; p = .333), hallux valgus angle (Pearson correlation coefficient -0.106; p = .330), nor sesamoid position (Pearson correlation coefficient 0.155; p = .157). The results of this investigation uniquely consider measurement of hypermobility as a continuous variable, and find no correlation between first ray sagittal plane motion and radiographic parameters associated with the hallux valgus deformity. These results might indicate that although the concept of hypermobility has traditionally been coupled with presentation of the hallux valgus deformity, this might simply represent the result of a historical confirmation bias., (Copyright © 2023 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The common treatments used to repair fingertip defects remain controversial. We have previously conducted research on split-thickness nail bed flaps, but this method still damages the proper plantar digital arteries and nerves. The great toe terminal branch arteries (TBAs) have not been described in detail., Methods: Twenty cadaveric feet were used to dissect the terminal branches of the plantar arteries. The locations and diameters of the terminal branches were analyzed. Five patients underwent operations with a TBA split-thickness nail bed flap. We recorded the recovery of both the donor and recipient sites and evaluated the results., Results: The diameter of the TBAs was between 0.4 and 0.8 mm. The TBA split-thickness nail bed flaps of five patients survived. No complications were found in any of the patients. The nail outcomes were excellent (A) in four patients and very good (B) in one patient. All patients were satisfied with the appearance of the recipient and donor sites. The mean static two-point discrimination was 6.0 mm (range, 4-9). The mean Semmes-Weinstein monofilament test score was 3.03 g (range, 1.65-3.84). Patients neither experienced severe pain in the reconstructed finger or at the donor site, nor did they experience severe cold intolerance. This microsurgical technique avoids the destruction of the proper plantar digital arteries and nerves., Conclusions: A TBA split-thickness nail bed flap from the great toe is clinically feasible and can achieve satisfactory results in fingertip repair., Clinical Question/level of Evidence: Therapeutic, V., Competing Interests: Declaration of Competing Interest None., (Copyright © 2023 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Introduction: How to reconstruct the damaged fingertip is a clinical problem. Our team propose the theory of equivalent design and use the mini toenail flap pedicled with the hallux transverse artery and toe pulp vein transplantation technique to reconstruct Allen's type II fingertip injury. Thus, we perform the retrospective study to evaluate the effects of this technique on fingertip injury., Materials and Methods: A retrospective analysis was performed on 56 patients admitted to our hospital from January 2015 to January 2020 who used equivalently designed miniature hallux toenail flaps for the plastic repair of fingertip damage. We recorded the size of the miniature hallux toenail flap, operation time, intraoperative blood loss, and complications and calculated the survival rate of the transplanted miniature hallux toenail flap. During routine follow-up after surgery, we recorded nail growth time and observed finger appearance. At the last time of follow-up, we recorded Semmes-Weinstein evaluating tactile sensation and Two-point discrimination testing (TPD). The efficacy was evaluated by Zook score evaluation., Results: The size of the mini hallux toenail flap was 0.71 cm × 1.22 cm to 0.88 cm × 1.71 cm. The operation time was (3.54 ± 0.58) hours, the intraoperative blood loss was (20.66 ± 4.87) ml, and the survival rate of mini hallux toenail flaps was 100%. The postoperative follow-up time was (30.82 ± 11.21) months, and the total nail growth time was (9.68 ± 2.11) months. The average tactile sensation evaluated by the Semmes-Weinstein test was (0.32 ± 0.14) g, and the average TPD was (7.33 ± 1.02) mm. According to Zook score, the curative effect of fifty-six cases were all excellent or good with 100% excellent and good rate, and all patients had beautiful appearances and good function of damaged fingertips., Conclusions: Based on the equivalent design theory, the mini hallux toenail flap pedicled with the hallux transverse artery and toe pulp vein transplantation technique is an effective method to reconstruct Allen's type II fingertip injury with a beautiful appearance and good function., Type of Study/level of Evidence: Therapeutic IV., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Recently, there have been new advances in the arthroscopic approach to small joints of the foot. This is directly related to the improvement of surgical equipment, new techniques, and publications. These improvements led to broadening indications as well as minimizing complications. Several articles recently presented the uses of arthroscopic surgery in the small joints of the foot; however, the use is still relatively limited. Arthroscopic evaluation of the small joints of the foot includes the first metatarsophalangeal, lesser metatarsophalangeal, tarsometatarsal, talonavicular, and calcaneocuboid joints as well as the interphalangeal joint to the great toe and lesser toes., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Treating osteochondral lesions of the first metatarsal head can help reducing pain and preventing end-stage arthritic cartilage degeneration and hallux rigidus. Several surgical techniques have been described, but no clear indications are reported. This systematic review aims to offer an overview of the current surgical treatments for focal osteochondral lesions of the first metatarsal head., Methods: The selected articles were examined to extract data about population, surgical technique, and clinical outcomes., Results: Eleven articles were included. Mean age at surgery was 38,2 years. Osteochondral autograft was the most used technique. After surgery, an improvement was achieved in AOFAS, VAS, and hallux dorsiflexion but not in plantarflexion., Conclusion: There is limited evidence and knowledge regarding the surgical management of the first metatarsal head osteochondral lesions. Various surgical techniques have been proposed, drawn from other districts. Good clinical results have been reported. Further high-level comparative studies are necessary to design an evidence-based treatment algorithm., Competing Interests: Declaration of Competing Interest We are submitting the manuscript for publication consideration in FOOT AND ANKLE SURGERY entitled “SURGICAL MANAGEMENT OF OSTEOCHONDRAL LESIONS OF THE FIRST METATARSAL HEAD: A SYSTEMATIC REVIEW” written by Elena Artioli, Antonio Mazzotti, Simone Ottavio Zielli, Alberto Arceri, Laura Langone, Simone Gerardi, and Cesare Faldini. None of the authors has a conflict of interest that could inappropriately influence this work., (Copyright © 2023 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Acquired hallux varus deformity secondary to postburn contracture is a rare condition. It causes cosmetic disfigurement, pain, and inability to wear a shoe. Soft-tissue procedures and tendon transfers have been described for correction; however, these may require multiple operations and the outcome may be poor. We report a 6-year-old neglected case of hallux varus deformity secondary to burn contracture successfully managed by contracture release with pivotless distraction technique using a biplanar distractor and skin grafting with Z-plasty in the same procedure. The deformity was corrected to a lesser extent and with good functional outcomes. The scar was excised and Z-plasty was performed. The medial joint capsule was released. We used gradual differential distraction with monitoring on sequential radiographs. Pain-free flexion of 45° and extension of 40° were achieved and the patient was able to wear shoes after 4 weeks postoperatively. Hallux varus is a multidimensional deformity. A severe and rigid deformity might not respond well to tendon transfers in a single stage. Our described technique can be used to correct rigid hallux varus deformity with preservation of joint function.

Nevoid melanoma (NeM) is a rare variant of malignant melanoma characterized by slight cellular atypia, polymorphism, and incomplete maturation. It most frequently occurs on the trunk and arms but rarely on the foot. Here, we report a subungual NeM of the right hallux. A 65-year-old man presented with severe pain of 6 months' duration to his right great toe following self-treatment for an ingrown nail. He was evaluated and treated with debridement of the toenail at an urgent medical center 3 months prior. However, this had not relieved his pain. The patient also noticed discoloration of his distal great toe over the past 3 months. Removal of part of the ingrown nail revealed a pigmented mass extending distally from the matrix. Surgical excision of the mass was performed because of the concern for malignancy. The diagnosis of NeM was based on histologic analysis along with enhanced diagnostic modalities. The patient was further treated with surgical amputation of the great toe and anti-programmed cell death-1 therapy. The patient had no relapse at 1-year follow-up. Nevoid melanoma is a rare variant of malignant melanoma on the toes, which needs to be differentiated from a nevus with atypia, with a variety of modalities including cellular and molecular profiling. The optimal treatment is amputation.

The research results are inconsistent that assessing whether the increased obliquity of the distal articular surface of the medial cuneiform leads to an increase in hallux valgus angle. Thus, this study investigated the relationship between distal medial cuneiform obliquity and hallux valgus by measuring various angles in weightbearing anteroposterior radiographs of the foot. In total, 679 feet of 538 patients with the radiographs were included in the study. We measured radiographic parameters including hallux valgus angle, first to second intermetatarsal angle, metatarsus adductus angle, first metatarsus cuneiform angle, distal medial cuneiform angle, and first proximal metatarsal articular angle. The surface morphology (flat or curved) of the first tarsometatarsal joint was also recorded. Our results analysis revealed a weak negative correlation between distal medial cuneiform angle and both hallux valgus angle and first to second intermetatarsal angle, contrary to our assumption. So we believe that distal medial cuneiform angle was relatively constant and it cannot be used as a characteristic angle for quantifying hallux valgus. First metatarsus cuneiform angle was a characteristic indicator of hallux valgus and was positively correlated with its severity (p < .000), indicating that it can be used to measure the size of hallux valgus. It can also be used as a reference factor for the first metatarsal osteotomy in clinical bunion orthopedics. First tarsometatarsal joint morphology was unrelated to hallux valgus, whereas metatarsus adductus angle, and first proximal metatarsal articular angle should be considered in hallux valgus., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

A frontal plane metatarsal rotational (pronation) has been documented in a high percentage of hallux valgus patients. Pathoanatomical concepts leading to pronation are still debated. Nevertheless, there is no consensus on how to measure this component of the deformity. The aim of the present study was to compare three commonly used radiographic methods to measure the frontal plane deformity in hallux valgus deformity, such as 1. Round sign of the lateral edge of the first metatarsal head on anterior-posterior radiograph, 2. Non-weightbearing CT-scan and 3. Bernard's axial projection of the first metatarsal head. Afterwards, feet were dissected, and a direct measurement of the pronation was done. Our data showed that alpha angle measurements made through the Bernard's axial projection were closer with those obtained during the dissection compared to those made through the CT-scan. The main finding of our study is that osteoarthritic changes at the metatarso-sesamoid joint play an important role in severe hallux valgus cases. The proposed radiographic methods allow surgeons to verify whether rotation can be corrected during Hallux Valgus procedures and to determine which procedure may be the best for each patient., (Copyright © 2022 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Arthrodesis of the great toe joint is a valuable procedure for hallux valgus deformities. The primary aim of this study was to determine nonunion rates of a first metatarsophalangeal joint (MTPJ) arthrodesis for bunion deformity. This was a retrospective review of 166 consecutive limbs that underwent a first metatarsal phalangeal joint arthrodesis at Wake Forest Baptist Medical Center (WFBMC). Procedures were performed using 4 different constructs for the arthrodesis. Incidence of nonunion, intermetatarsal correction, infection, and recurrence were measured. Overall, 20 patients (12%) experienced nonunion following a first metatarsophalangeal joint arthrodesis. Eighty-seven patients (86%) of plate and screw patients achieved union while 14 (78%) of crossing screw patients achieved union. The minimum time of follow-up was 3 months and the maximum time was 15.4 months. The mean change in intermetatarsal and hallux valgus angle correction was 3.4° and 20.3°, with no statistical difference based on hardware construct or being diabetic. First metatarsophalangeal joint arthrodesis is a viable option for hallux valgus. However, the results of the present study suggest that there is a lower fusion rate of the first MTPJ using crossing screws for bunion deformities., (Copyright © 2023 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Introduction: Plantar hallux wounds are common in patients with diabetic neuropathy. Several techniques, both surgical and nonsurgical, are designed to offload plantar wounds. However, controversy exists regarding which techniques are superior in terms of efficacy, safety, and longevity., Objective: This manuscript presents a simple, minimally invasive technique to permanently offload the plantar IPJ of the hallux in the case of recalcitrant plantar ulcerations. The authors describe their surgical technique for and outcomes of medially based hallux IPJ arthroplasty for the management of recalcitrant hallux ulcerations., Materials and Methods: Five patients (6 wound cases) were evaluated. All patients underwent the same surgical procedure and were subject to the same postoperative protocol of full weight-bearing as tolerated., Results: All 5 cases healed, with an average time to healing of 15.5 days (range, 10-22 days) and no instances of recurrence. The average time to final follow-up was 83.17 weeks (range, 54-95 weeks)., Conclusions: The medially based hallux IPJ arthroplasty approach has demonstrated ability to adequately offload hallux ulcerations, permits bone biopsy or resection for treatment of underlying bone infection, and allows for immediate weight-bearing.

Osteoid osteoma (OO) is a benign osteoblastic bone tumor typically involving the diaphysis or metaphysis in long tubular bones. OO in phalanges of the great toe has been rarely reported, and it is often challenging to differentiate with subacute osteomyelitis, bone abscess, or osteoblastoma. This case report describes an uncommon case of a 13-year-old female patient with subperiosteal OO in the proximal phalanx of the great toe. The atypical location of OO should be familiarized to include appropriate differential diagnosis and to ensure accurate diagnosis by radiologic evaluations. Surgical excision remains the benchmark for the treatment of OO with its advantages on direct visualization and histologic confirmation for the diagnosis., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Background: Hallux ulcers are known for their recurrence and associated risk for future amputations. Traditional nonsurgical external offloading methods have poor compliance rates, and the data is sparse on surgical offloading of hallux ulcers. We performed this study to analyze the outcomes of Keller excision gap arthroplasty of the first metatarsophalangeal joint in patients with a neuropathic plantar hallux interphalangeal joint (IPJ) ulcer in patients with diabetes mellitus., Methods: A retrospective study of 105 diabetic patients with a plantar hallux IPJ ulcer who underwent a Keller excision gap arthroplasty between December 2014 and June 2020 was done. A total of 122 great toes had been operated upon for hallux IPJ ulcers. We studied the long-term wound healing rates from patient records and then did a prospective survey of the postreview period., Results: All the hallux IPJ ulcers healed well in the immediate postoperative period. Six patients reported a recurrence of the ulcer at the original site during a mean follow-up period of 30 months. For these 6 patients, the mean time to recurrence of ulcer after operation was 2.5 years., Conclusion: At an average of 30 months, we found the Keller gap arthroplasty for treatment of noninfected and nonischemic diabetic foot hallux IPJ ulcers was associated with an ulcer recurrence rate of 5%., Level of Evidence: Level IV, cohort study.

Distal injury in thumbs and fingers is common in emergency. Although multiple surgical techniques have been introduced for repair purpose, it is still challenging for restoring both good function and cosmetic appearance. The present study reports our experiences on how to reconstruct amputated fingertips in thumbs and fingers using a mini hallux neurovascular osteo-onychocutaneous free flap with favorable outcomes in 15 patients (average age, 27.27 ± 5.43 years old). Follow-up period was 19.47 ± 10.18 months (range, 6-48 months). Digital function was improved indicated by the static two-point discrimination (2-PD) and key-pinch, which were 8.40 ± 1.64 mm (range, 6-12 mm) and 85.37 ± 3.03% (range, 80.2-90.6%) of that of the intact contralateral thumbs and fingers, respectively, after surgery. As to aesthetic outcomes, all reconstructed digits were self-graded as good by patients. 73.3% of the donor halluces were self-graded as good and four halluces (26.7%) were graded as fair . In conclusion, the mini hallux neurovascular osteo-onychocutaneous flap may be used for refined reconstruction of type I amputated injury in thumbs and fingers achieving both satisfactory functional and aesthetic outcomes.

Painful ganglion cysts that develop in the hallux and finger usually enlarge progressively to the peripheral direction. Simple resection of satellite ganglion cyst alone has been reported to cause a high rate of recurrence and treatment is often very difficult. The purpose of this study is to evaluate the appropriate surgical treatment for painful satellite ganglion cysts in the hallux and finger and discuss the origin of the ganglion cysts in cases treated surgically at our hospital. We reviewed five cases (three males and two females, ages 55-87 years), three of which occurred in the hallux and two in the finger. In all cases, the preoperative magnetic resonance image showed a large fluid of the flexor tendon sheath. And also, joint effusion was found in the metatarsophalangeal joint and the proximal interphalangeal joint. The first case of the hallux ganglion underwent simple excision of the cyst and had recurrences three times. In the other four cases, the additional synovectomy of the metatarsophalangeal joint and the proximal interphalangeal joint was performed along with ganglion cyst excision. These cases had no recurrence up to 1 year after operation. Recently, there have been reports that tendon sheath ganglions are connected to the ankle, wrist, hallux, and phalangeal joints. Although there are a few cases in our department, satellite ganglion cyst of the hallux and finger possibly originates from adjacent joints. Additional synovectomy of the affected joint should be performed for the excision of satellite ganglion cyst to prevent recurrence., (© Japan College of Rheumatology 2022. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: The aim of this study was to compare outcome (clinical, patient-reported outcome measures, radiologic, joint motion and pedographic) of total joint replacement with Roto-Glide (RG) and arthrodesis (A) for severe osteoarthritis of the first metatarsophalangeal joint (MTP1)., Methods: All consecutive patients with arthrodesis and RG from January 23, 2011, until September 18, 2019, at the authors' institution were considered for inclusion in the study. Preoperatively and at follow-up (FU), radiographs, and/or weightbearing computed tomographic imaging were obtained. Standard dynamic pedography was performed. Visual analog scale foot and ankle (VASFA), European Foot and Ankle Society (EFAS) score, MTP1 range of motion for dorsiflexion/plantarflexion (DF/PF) were registered and compared preoperatively and at FU., Results: Seventy RG and 72 arthrodesis patients were included. Preoperative VASFA and EFAS scores did not differ between the RG and arthrodesis groups (average scores: VASFA, 50.6 and 45.6; EFAS score, 10.7 and 10.6, respectively; each P > .05). Wound healing delays without further operative measures were registered in 4 patients (6%) for RG and 5 (7%) for arthrodesis ( P = .67), and 5 revisions in 5 patients (7%) for RG and 12 in 8 (11%) for arthrodesis ( P = .05). The longest available FU was higher in RG than in arthrodesis (47 vs 37 months on average, P < .001). Pedography showed higher first metatarsal head or sesamoids and lower great toe force percentage from force of entire foot in RG than in arthrodesis ( P = .05) resulting in physiological pattern in RG only. VASFA and EFAS scores at FU was higher in RG than in arthrodesis (average scores: VASFA, 72.6 and 63.6; EFAS score, 16.1 and 14.1, respectively; each P < .05). DF/PF measurement was only possible in RG (average value: DF/PF, 36.1/14.0)., Conclusion: We found marginally lower revision rates and higher patient-reported outcome measures, joint motion (DF/PF), and more physiologic force distribution at slightly longer FU for the RG group than the arthrodesis group. Longer follow-up and broader clinical reporting are needed to identify the potential deficits of RG., Level of Evidence: Level III, retrospective cohort study.

Background: This study compared radiographic and functional patient outcomes of 1st MTP arthrodesis between hallux rigidus (HR) and hallux valgus (HV) cohorts., Methods: A retrospective review was conducted at an academic medical center on patients who underwent 1st MTP arthrodesis during 2009-2021. In total, 136 patients (148 feet: HR=57, HV=47, combined=44) met the inclusion criteria of minimum three-month follow-up (mean=1.25 years, range=0.25-6.14 years). Data collection included patient-reported outcome measures (PROMs), radiographic markers, and complication and reoperation rates., Results: PROMs improved overall, with HV patients significantly improving the least. The HR group had a significantly smaller improvement in HV angle (HR=-3.6, HV=-17, Combined=-15 p < .001), intermetatarsal angle (H=-0.16, HV=-2.8, Combined=-2.6 p < .001), and 1st-5th metatarsal width (HR=-0.98, HV=-4.6, Combined=-4.6, p < .001). Complication and reoperation rates did not differ by group., Conclusion: Outcomes of 1st MTP arthrodesis does not appear to differ between diagnostic indications of hallux rigidus, hallux valgus, or both., Level of Evidence: Level III, Retrospective cohort study., Competing Interests: Declaration of Competing Interest The authors declare that there is no conflict of interest., (Copyright © 2022 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Hallux metatarsophalangeal joint (MTPJ) arthrodesis was first described in 1894 by Clutton, who recommended ankylosing the MTPJ to treat painful hallux valgus (HV). He used ivory pegs to stabilize the MTP joint. Surgeons over the last century have modified the procedure and added indications, including hallux rigidus, rheumatoid arthritis, and revision of failed surgeries. This article addresses many common yet challenging clinical scenarios, and a few hot topics, related to hallux MTPJ arthrodesis, including matarsus primus elevatus, severe hallux valgus, avascular necrosis, and infections. The article provides a condensed evidence-based discussion on how to manage these challenges using MTPJ arthrodesis., Competing Interests: Disclosure A.K. Attia: Nothing to disclose. K.A. Heier: Royalties from I2Bone. Stock ownership 4Web, I2B., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: At the time of the first report on the feasibility of corrective osteotomies of the distal phalanx (DP) of the great toe there were no published studies addressing this type of surgery. Along this line, and throughout our clinical experience, this paper tries to show the clinical benefits of hallux DP osteotomies when correcting interphalangeal valgus deformities (IHV) of the great toe, either with open or percutaneous procedure., Material and Methods: This is a review of 18 cases in which a DP osteotomy was performed in 2 different institutions, 8 cases were performed using open technique and 10 cases percutaneously. The correction obtained was analyzed by measuring the distal articular set angle (DASA), obliquity angle (AP1), asymmetry angle (AP2), and global distal phalanx deviation (GDPD) angle before and after the surgery on dorso-plantar weight-bearing radiographs in all cases. Clinical results were also recorded., Results: Excellent clinical and radiological results were achieved with both techniques in all patients with no complications. The average DP angular deformity correction in terms of AP1, AP2 and GDPD angles were 4.58º ± 5.55º, 8.95º ± 4.77º and 16.53º ± 7.26 respectively. In 10 cases an Akin osteotomy was associated., Conclusion: In cases with valgus deviation in the hallux DP, a corrective osteotomy of the DP alone or associated to osteotomy of the PP should be considered as a useful tool. The technique is feasible and has no technical difficulties for an orthopedic surgeon with experience on feet surgery., Competing Interests: Conflict of interest The authors declare that they have no conflict of interest., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

An atraumatic rupture of the extensor hallucis longus tendon is a rare injury. Chronic overload due to contact sports, bony anomalies, previous operations, and drug injections close to the tendon have been reported as a cause. We report the case of a young patient who presented with an acute loss of function in his extensor hallucis longus tendon for no apparent reason., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Thieme. All rights reserved.)

We present a case of a 25-year-old male professional soccer player who complained of severe pain over the first metatarsal head after opponent contact during a soccer game. Clinical findings showed swelling and tenderness. Initial radiographs showed a diastasis of a bipartite medial sesamoid between the fragments as compared to radiographs taken 4 years earlier of the same foot. A computed tomography scan was performed objectifying the widened interval and also showing an angulation of the proximal fragment. Open reduction and screw fixation were performed, leading to adequate positioning of the 2 bipartite fragments. The patient showed good clinical recovery and returned to the same performance level. Turf toe injury with diastasis of a medial bipartite sesamoid can be treated successfully with this operative technique. Levels of Evidence: Level V: Case report.

To explore the clinical outcome of a free great toe nail flap (GTNF) combined with a second toe tissue flap (STTF) for fully shaped finger reconstruction (FSFR). From January 2013 to January 20, 2019, patients with finger defects underwent finger reconstruction using free GTNF combined with an STTF. All 20 fully shaped, reconstructed fingers survived without complications. The average follow-up time was 44.4 months (range 12-60 months). The reconstructed fingers had better function and appearance. The length of the fingers was close to normal, and the joint positions were normal. The fingers were able to extend -15° to -5° and flex 40° to 85°. The reconstructed fingers had no pain or numbness, and the function of the feet was restored well. The reconstruction of fully shaped fingers using GTNF combined with an STTF results in better function and appearance. This surgical method is worthy of promotion. This article introduces a new surgical method that is related to finger reconstruction. Finger defects bring psychological and functional regrets to patients and their families. Through this operation, the reconstructed finger is more perfect in appearance and function. I think this technology is very effective and worth promoting., (© 2021 The Authors. International Wound Journal published by Medicalhelplines.com Inc (3M) and John Wiley & Sons Ltd.)

Objective: To analyze the biomechanical changes of hallux valus after Swanson prosthesis-arthroplasty of the 1st metatarsophalangeal joint combined with osteotomy and bone grafting of the 1st metatarsal bone by three-dimensional finite element analysis, so as to provide data basis for studying the changes of foot morphology and physiological function after hallux valus correction surgery., Methods: A 65-year-old female patient with severe hallux valus admitted in January 2013 was selected as the research object. The CT data of the right foot was obtained, and the three-dimensional finite element models before and after Swanson prosthesis-arthroplasty of the 1st metatarsophalangeal joint combined with osteotomy and bone grafting of the 1st metatarsal bone were established by Mimics10.01, Geomagic Studio, and ANSYS12.0 software. ANSYS 12.0 software was used for nonlinear static stress analysis, and the hallux valgus angle (HVA), the intermetatarsal angle (IMA), and the von Mises stress distributions of the forefoot plantar surface and the 1st to 5th metatarsal bones were observed before and after operation., Results: The HVA and IMA were 56.3° and 16.3° before operation and 9.2° and 9.8° after operation, respectively. Before operation, the stress on the forefoot was the largest in the 4th metatarsal head zone and the smallest in the 1st metatarsal head zone; the stress on the medial side of the forefoot was significantly smaller than that on the lateral side, and the center of forefoot pressure was located on the lateral side. After operation, the stress on the forefoot was the largest in the 1st metatarsal head zone and the smallest in the 5th metatarsal head zone; the stress on the lateral side of the forefoot was significantly smaller than that on the medial side, and the center of forefoot pressure was located on the medial side. Before operation, the stress of the 5th metatarsal bone was the largest, and the 1st metatarsal bone was the smallest. After operation, the stress of the 1st metatarsal bone was the largest, and the 4th metatarsal bone was the smallest., Conclusion: Swanson prosthesis-arthroplasty of the 1st metatarsophalangeal joint combined with osteotomy and bone grafting of the 1st metatarsal bone can effectively correct hallux valgus and make HVA, IMA, and plantar pressure distribution close to normal. However, postoperative stresses of the 1st to 5th metatarsal bones elevate, which may lead to associated complications.

Longitudinal epiphyseal bracket of the first metatarsal, also known as first enclosed metatarsal, is a rare congenital disorder characterized by an abnormal development in the length of the first metatarsal ray because of the asymmetric presence of a longitudinal epiphyseal bracket. This causes interruption in the lengthways development of the affected bone, which becomes squat and short, with a trapezoidal or triangular shape, leading to a hallux varus deformity. First enclosed metatarsal occurs in 2% to 14% of all congenital defects in the hands and feet; with bilateralism in 75% of cases and a greater incidence in male patients. The deformity is classified as a differentiation defect; it is frequently associated with abnormalities such as syndactyly or polydactyly. There are different surgical treatments reported in the literature. Most of them are aimed at the excision of the epiphyseal bracket before complete skeletal maturity and frequently in the first year of life to promote a normal lengthways growth of the bone. In this study, the authors present three cases of bilateral first enclosed metatarsal in which the surgical treatment, aimed at lengthening the first metatarsal ray by using the Penning Minifixator, was instead carried out at the end of growth. This different surgical approach allowed the planning of a surgical operation involving both the skeletal structures and the surrounding soft tissue.

Hallux rigidus is the degenerative pathology of the metatarsophalangeal joint of the hallux. This pathology causes pain and decreased movement. There are multiple surgical treatments for this pathology, all with their respective indications. We present the case of a 54-year-old patient diagnosed with hallux rigidus who had only the lateral aspect of the metatarsal head affected. This patient was treated with a novel surgical procedure, performing an interposition hemiarthroplasty using the hallucis brevis extender associated with a cheilectomy and exostectomy. The patient had a favorable clinical evolution with improvement evidenced by clinical scales, with resolution of the symptoms and without complications. Interposition hemiarthroplasty using the extensor hallucis brevis is a successful joint and movement preservation treatment for hallux rigidus in young patients with lateral unicompartmental involvement of the metatarsal head, in whom it is important to preserve movement.

Objective: To explore the clinical effects of free superficial peroneal artery perforator flaps in repairing skin and soft tissue defects of the hallux. Methods: A retrospective observational study was conducted. From January 2020 to January 2021, 13 patients with skin and soft tissue defects of the hallux who met the inclusion criteria were admitted to Department of Foot and Ankle Surgery of Ruihua Affiliated Hospital of Soochow University, including 12 males and 1 female, aged 26 to 53 years. Before operation, the perforating point of the superficial peroneal artery perforator was located by color Doppler ultrasound on the calf on the same side of the affected hallux and marked on the body surface. The operation was performed under spinal anesthesia combined with continuous epidural anesthesia. The area of skin and soft tissue defect after debridement was 4.5 cm×2.5 cm to 12.0 cm×3.0 cm. According to the size and shape of the wound, the superficial peroneal artery perforator flap was designed with the line between the fibular head and the lateral malleolus tip parallel shifting 2 cm to the tibial side as the flap axis line, and the perforating point of the perforator near the midpoint of the axis line as the center. The cut area of the flap was 5.0 cm×3.0 cm to 13.0 cm×4.0 cm, and part of the deep fascia was cut when the pedicle was freed. The donor site wound was sutured directly. During the operation, the number and type of the perforator and the cutting time of the flap were recorded, and the length of the perforator pedicle and diameter of the perforator were measured. The survival of the flap, the healing time and the healing condition of the donor and recipient areas were recorded after operation. The color, texture, elasticity of the flap, standing and walking functions of patients, the recovery of the donor area, and the patients' satisfaction with the recovery of the donor and recipient areas were recorded during the follow-up. At the last follow-up, the sensation of the flap was evaluated by the British Medical Association sensory function evaluation standard, the function of the affected limb was evaluated by the American Society of Foot and Ankle Surgery scoring system, and the excellent and good rate of the function of the affected limb was calculated. Results: A total of 13 perforators of the superficial peroneal artery were detected during the operation, all of which were septocutaneous perforators, and the perforator diameter was 0.3 to 0.5 mm. The vascular pedicle length was 2 to 5 cm. Flap cutting time was 11 to 26 minutes. The flaps of 13 patients all survived completely. The wounds at the donor and recipient sites healed well 9 to 18 days after operation. During follow-up of 6 to 14 months, the flaps had good color, texture, and elasticity; 11 patients had no obvious bloated appearance, and the other 2 patients underwent flap thinning and plastic surgery in the second stage because of their bloated appearance; all the patients returned to normal walking and standing functions. There was only one linear scar left in the donor site, with no obvious scar hyperplasia or hyperpigmentation. All the patients were satisfied with the recovery of the donor and recipient areas. At the last follow-up, the sensation of the flap was evaluated as grade S 3 in 2 cases, grade S 2 in 9 cases, and grade S 1 in 2 cases; the function of the affected limb was evaluated as excellent in 7 cases and good in 6 cases, with an excellent and good rate of 100%. Conclusions: The free superficial peroneal artery perforator flap has relatively constant vascular anatomy, which is thin and wear-resistant, with less damage to the donor site after flap excision, and can preserve the shape and function of the hallux to the greatest extent. It is an effective method for repairing skin and soft tissue defect of the hallux.

Checkrein deformity (CD) is a dynamic deformity of the hallux characterized by flexion contracture of the interphalangeal (IF) joint and extension contracture of the metatarsophalangeal (MTP) joint, worsened by ankle dorsiflexion. It is due to post-traumatic or ischemic retraction of the long hallux flexor tendon (FHL) following soft tissue trauma, leg fractures, ankle fractures and, more rarely, calcaneal or talar fractures. Diagnosis is essentially clinical, associated with imaging, to rule out unrecognized causes and evaluate fracture healing process. Few cases are reported in literature without univocal treatment. Background and Objectives: To analyze clinical and functional outcomes in patients with CD treated with release and retro-malleolar Z-plasty lengthening of FHL tendon. Materials and Methods: Patients diagnosed with CD treated with retro-malleolar (at tarsal tunnel) Z-plasty lengthening of the FHL tendon between January 2016 and August 2020 were included. Clinical and functional outcomes were collected on admission and post-surgery and analysed retrospectively. Patients with a minimum follow-up of 18 months were included. Results: A total of 14 patients, with mean age of 37.4 years old, with CD diagnosis were included in the study. All patients were suffering from post-traumatic CD and the mean time from trauma to onset of deformity was of 7 months (range 1−12). At a mean follow-up of 31.8 months (range 18−48) we found a significant improvement (p < 0.05) in terms of pain relief (VAS), function (AOFAS score) and ROM of the IP and MTP hallux joints. No recurrence, loss of strength, nerve injury or tarsal tunnel syndrome were observed. No patient required revision surgery. Conclusions: In this case series the retro-malleolar FHL tendon Z-plasty proved to be a suitable option for CD correction, allowing a good clinical and functional recovery.

Background: We present an unusual technique for reconstruction of a postoperative tissue defect following hallux rigidus surgery., Methods: A complicated course after left big toe arthrodesis resulted in a soft tissue defect with bone exposure of the first ray. Amputation of the big toe was categorically rejected by the patient. There was advanced arteriosclerosis with single-vessel supply to the foot via the posterior tibial artery., Outcome: To preserve the big toe, the defect was covered by a fasciocutaneous radial free flap with a 15 cm long vascular pedicle which was microanastomosed to the posterior tibial artery and its accompanying vein at the level of the medial malleolus., Conclusion: In certain extreme situations, the free "Chinese" radial flap can be quite effective in covering forefoot defects and allowing satisfactory and aesthetically pleasing soft tissue reconstruction., Competing Interests: The authors declare that they have no conflict of interest./Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Purpose: In finger reconstruction, big-toe wraparound flap (WAF) transfer provides excellent results. However, difficulty in healing and impaired function at the donor site are common. We aimed to explore an ideal method to address these complications., Methods: This retrospective study involved 22 patients who were treated with big toe WAF transfer for finger reconstruction between 2016 and 2020. Patients were categorized into cohorts by donor site repair method: second-toe medial-side adjacent toe flap and skin graft (cohort 1) and skin graft alone (cohort 2). Functional outcomes, aesthetic appearance, and complications at the donor site were compared. Functional outcomes were assessed according to the American Orthopaedic Foot and Ankle Society (AOFAS) for hallux metatarsophalangeal-interphalangeal score, Foot Function Index-Verbal Rating Scales (FFI-5 pt), and visual analog scale for pain. Aesthetic appearance was evaluated according to the adjusted question 28 in the Michigan Hand Outcome Questionnaire., Results: The mean pain scores in AOFAS and FFI-5 pt were 38.00 ± 4.22 and 3.75 ± 2.37, and 32.50 ± 4.52 and 6.60 ± 2.14 in cohorts 1 and 2, respectively, which showed no significant differences. The method in cohort 1 can reduce the level of pain. This was further confirmed by visual analog scale scores of 3.40 ± 0.84 and 6.42 ± 7.93 in cohorts 1 and 2, respectively. The mean functional scores in AOFAS and FFI-5 pt were 38.40 ± 2.37 and 1.25 ± 1.62, and 37.92 ± 2.15 and 1.56 ± 2.11 in cohorts 1 and 2, respectively, which showed no significant differences. Eight patients developed complications: 1 patient (1/10 [10%]) in cohort 1 developed a superficial infection, and in cohort 2, 7 patients (7/12, 58.30%) developed complications, including 2 short-term complications with partial necrosis and 1 delayed healing. Long-term complications included the following: scar discomfort (2 cases), pain discomfort (1 case), and skin ulceration due to repeated wear and tear (1 case). Cohort 2 had significantly more complications than cohort 1., Conclusions: Second-toe medial-side adjacent toe flap combined with skin graft had better aesthetic appearance, less complications, and less pain compared with skin graft alone. Hence, it can be a reliable technique for repairing the donor site after big-toe WAF transfer., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)