RESUMEN
BACKGROUND: Isolated degenerative joint disease and/or Freiberg's infraction of the lesser metatarsophalangeal joint, although not frequent may become debilitating in the younger individual. Currently, once conservative management fails, the mainstay of treatment is debridement and excision-interposition arthroplasty. Replacement arthroplasty has been ineffective in the long term as the joints are subject to severe repetitive fatigue loading over small articulating surfaces through a wide range of motion. This is an in vitro and cadaver study of a new design replacement arthroplasty developed by the senior author. The aim of this study is to evaluate this novel replacement arthroplasty of the lesser metatarsophalangeal joint in a laboratory setting and cadaver implantation. METHODS: This three-component mobile bearing device is made of titanium and high density polyethylene which evolved over 4 years. It was subjected to 5,000,000 cycles in a laboratory under physiological and excessive forces to assess resistance to fatigue failure and wear pattern of the polyethylene liner. Following these tests, it was implanted in 15 fresh frozen cadavers at various stages of its development, during which the surgical technique was perfected. Range of motion and stability was tested using custom made instrumentation in four cadavers. The implant was inserted in a further two cadavers by an independent foot and ankle surgeon to check reproducibility. RESULTS: The device showed almost no signs of wear or surface deformation under physiological forces. The surgical technique was found to be simple and reproducible in the cadaver trial. The average dorsiflexion was 28.5° and 28.9° pre- and post-implant respectively. The average plantar flexion was 33.8° and 20.8° pre- and post- implant respectively. The joints were stable both pre- and post-operatively. Post-operative stability was objectively assessed for dorsal displacement and dorsiflexion using a 5 kgf (49 N) and was found to be excellent. CONCLUSION: This novel lesser metatarsophalangeal joint replacement arthroplasty has been developed as an option in the surgical treatment of symptomatic degenerative joint disease and/or Freiberg's infraction resistant to conservative treatment. The implant was found to be durable and resistant to wear in the laboratory testing. The cadaver studies have shown it to require minimal specialized instrumentation with good surgical reproducibility. This proof of concept study is the basis for clinical trials.
Asunto(s)
Artroplastia de Reemplazo , Prótesis Articulares , Articulación Metatarsofalángica , Cadáver , Humanos , Articulación Metatarsofalángica/diagnóstico por imagen , Articulación Metatarsofalángica/cirugía , Reproducibilidad de los ResultadosRESUMEN
Acute great toe (Hallux) pain is a common complaint encountered by the primary care physician. Pathological conditions can vary from acute trauma to acute exacerbation of underlying chronic conditions. Delay in treatment or misdiagnosis can lead to debilitating loss of function and long-lasting pain. This review endeavors to discuss the pertinent history, physical exam findings, radiographic evidence, conservative treatment options, and surgical management for the musculoskeletal causes of acute and acute on chronic great toe pain in the adult population. The acute pathologies discussed in this review are hallux fractures and dislocations, turf toe, sand toe, and sesamoid disorders. The chronic pathologies discussed include hallux rigidus, hallux valgus, and chronic sesamoiditis.
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Traumatismos de los Pies/terapia , Fracturas Óseas/terapia , Hallux Rigidus/terapia , Hallux Valgus/terapia , Hallux/fisiopatología , Luxaciones Articulares/terapia , Tratamiento Conservador , Traumatismos de los Pies/diagnóstico por imagen , Fracturas Óseas/diagnóstico por imagen , Hallux Rigidus/diagnóstico por imagen , Hallux Valgus/diagnóstico por imagen , Humanos , Luxaciones Articulares/diagnóstico por imagen , Examen FísicoRESUMEN
BACKGROUND: Lesser toe metatarsophalangeal (MTP) joint pathology presents a challenge for surgical treatment. At our institution, arthroplasty using a polyvinyl alcohol (PVA) hydrogel implant has been utilized in the second and third MTP joints for advanced arthritis, failed management of Freiberg's infraction, and osteochondral defects. We present a case series describing the clinical outcomes of 13 patients following PVA implantation of the second or third MTP. METHODS: We retrospectively identified 13 patients (14 joints) who underwent PVA hydrogel implantation of the second (n = 12) or third (n = 2) metatarsal between 2017 and 2019. The average age was 49 (range, 20-67) years, with 100% females. Patient-Reported Outcomes Measurement Information System (PROMIS) scores were collected preoperatively and at an average of 21.1 (range, 8.3-29.2) months postoperatively. Clinical outcomes were also evaluated. The average time to clinical follow-up was 24.7 (range, 7-35.8) months. RESULTS: On average, patients demonstrated pre- to postoperative improvement in all PROMIS domains, with significant improvements in Pain Intensity (P = .01) and Pain Interference (P = .01). Five postoperative complications were observed: 1 case of persistent avascular necrosis, 1 revision with implant removal and bone grafting, 1 periprosthetic fracture, and 2 recurrences of pain requiring ultrasound-guided injection. CONCLUSION: This study represents the largest case series to date evaluating the use of PVA implant in the surgical correction of lesser toe MTP joint pathology. While the PVA implant presents a viable option in the setting of advanced arthritis, Freiberg's infraction, and certain osteochondral defects, it is not without complications. The specific indications for use of the PVA implant should be carefully considered. LEVEL OF EVIDENCE: Level IV, case series.
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Artroplastia/métodos , Articulación Metatarsofalángica/cirugía , Metatarso/anomalías , Osteocondritis/congénito , Alcohol Polivinílico/uso terapéutico , Prótesis e Implantes , Adulto , Anciano , Femenino , Humanos , Metatarso/cirugía , Persona de Mediana Edad , Osteocondritis/cirugía , Medición de Resultados Informados por el Paciente , Estudios Retrospectivos , Adulto JovenRESUMEN
BACKGROUND: Lesser toe metatarsal head degeneration and collapse can cause significant pain and disability. In the setting of global metatarsal head collapse, there are limited operative options. The purpose of our study was to evaluate clinical and radiographic outcomes after lesser toe metatarsophalangeal (MTP) joint interpositional arthroplasty with a tendon allograft and to describe the operative technique. METHODS: We retrospectively reviewed a consecutive series of patients treated by 3 fellowship-trained foot and ankle surgeons at one institution. We created a phone survey to evaluate satisfaction, pain, and likelihood to repeat the surgery. Foot and Ankle Ability Measure (FAAM) scores were reviewed before and after surgery. Preoperative and postoperative radiographs were evaluated for preservation of metatarsal length. The procedure was performed through a dorsal midline approach. The metatarsal head was reamed to a concave shape. A tendon allograft was fashioned into a ball and secured to the metatarsal with an anchor. Fifteen feet in 14 patients underwent lesser MTP joint interposition arthroplasty, with the average age of 49 years (range, 24-69), and an average follow-up of 4.2 years. RESULTS: Eighty percent (12/15) reported they would have the procedure again. Visual analog scale pain scores showed a decrease in pain from 7 to 1. FAAM sports subscale improved from 56% to 85%. Radiographically, the ratio of the affected metatarsal length to the adjacent metatarsal remained constant before and after surgery, suggesting preservation of the metatarsal cascade. CONCLUSION: Interpositional arthroplasty of the lesser MTP joints with a rolled tendon allograft provided a unique solution, as it allows the surgeon to fill a large void without harvesting an autograft. This study showed improved patient-reported outcomes, high patient satisfaction, and good radiographic outcomes. Lesser metatarsophalangeal joint allograft interposition arthroplasty was a viable solution as a salvage procedure in the setting of global metatarsal head collapse. LEVEL OF EVIDENCE: Level IV, retrospective case series.
Asunto(s)
Artroplastia/métodos , Tendones Isquiotibiales/trasplante , Artropatías/cirugía , Articulación Metatarsofalángica/cirugía , Adulto , Anciano , Aloinjertos , Humanos , Persona de Mediana Edad , Dimensión del Dolor , Satisfacción del Paciente , Estudios Retrospectivos , Encuestas y Cuestionarios , Adulto JovenRESUMEN
BACKGROUND: There is no consensus regarding which surgical technique is most beneficial for pathology of the second metatarsophalangeal joint. We report the use of polyvinyl alcohol hydrogel synthetic cartilage implant hemiarthroplasty for pathology of the second metatarsal head that has failed nonoperative treatment and present 5 cases with a minimum 15 months of follow-up. METHODS: The technique for synthetic cartilage hemiarthroplasty of the second metatarsal head is described. The postoperative protocol included weightbearing as tolerated for 2 weeks and moderate limitations in activities of daily living to respect wound healing, followed by physiotherapy for range of motion exercises. Charts for patients who underwent this procedure between 2015 and 2017 were retrospectively reviewed. Outcome measures collected postoperatively included a pain visual analog scale, Short-Form 36 (SF-36) Physical Component Summary (PCS) and Mental Component Summary (MCS) scores, and Foot and Ankle Ability Measure (FAAM) Sports and Activities of Daily Living (ADL) current level of function percentages. RESULTS: At 15 to 38 months of follow-up, patients reported little to no pain and good range of motion, with no complications. Mean outcome measure scores were 89 for FAAM ADL, 75 for FAAM Sports, 44.4 for SF-36 PCS, and 52.1 for SF-36 MCS. CONCLUSION: This preliminary study of synthetic cartilage hemiarthroplasty for treatment of joint-destructive conditions of the second metatarsal head demonstrated good outcomes and no complications in 5 cases at a mean 25 months of follow-up. Large prospective cohort studies are needed to prove the efficacy and safety of this new surgical technique for the treatment of pathology of the second metatarsal head. LEVEL OF EVIDENCE: Level IV, retrospective case series.
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Hemiartroplastia/métodos , Articulación Metatarsofalángica/cirugía , Alcohol Polivinílico , Prótesis e Implantes , Anciano , Evaluación de la Discapacidad , Femenino , Humanos , Masculino , Articulación Metatarsofalángica/patología , Persona de Mediana Edad , Rango del Movimiento Articular , Estudios RetrospectivosRESUMEN
Avascular necrosis of the foot and ankle is a rare but important cause of pain and functional abnormality. This process may occur in any bone in the foot and ankle; however, it presents most often in characteristic locations. Understanding of key radiographic findings is important in management of these lesions. MRI is the most sensitive and specific method for detection and characterization of this abnormality.
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Articulación del Tobillo/diagnóstico por imagen , Pie/diagnóstico por imagen , Osteonecrosis/diagnóstico por imagen , Articulación del Tobillo/patología , Femenino , Pie/patología , Humanos , Imagen por Resonancia Magnética/métodos , Masculino , Radiografía/métodos , Tomografía Computarizada por Rayos X/métodosRESUMEN
Although causes of metatarsalgia are multifactorial, in practice these most commonly include osseous stress reaction or fracture (including subchondral injury) and interdigital neuroma or plantar plate tear with adjacent pseudoneuroma. The various roles of radiography, ultrasonography, and MR imaging are discussed, and relevant technical issues and imaging findings are reviewed in order to facilitate accurate diagnosis and guide proper treatment of metatarsalgia.
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Metatarsalgia/diagnóstico por imagen , Metatarsalgia/etiología , Traumatismos en Atletas/diagnóstico por imagen , Diagnóstico Diferencial , Fracturas Óseas/diagnóstico por imagen , Humanos , Factores de Riesgo , Sensibilidad y EspecificidadRESUMEN
INTRODUCTION: Freiberg's infraction is an osteonecrosis affecting the metatarsal head whose pathogenesis is not fully understood, although stress overloading by multiple microtraumas remains the most widely accepted cause. Operative treatment, by different techniques, is necessary when conservative treatment fails. PRESENTATION OF CASE: A 31-year old woman presented with left foot severe pain, especially at the level of the metatarsophalangeal joint (MTPJ) of the second ray, underestimated upon initial evaluation. She had a history of repetitive microtraumas, a long second metatarsal bone and altered forefoot kinematics. Clinical and radiographic findings were compatible with Freiberg's infraction. A dorsal closing-wedge osteotomy with single screw stabilization was performed. At last follow-up, the patient was completely asymptomatic with a normal MTPJ range of motion. DISCUSSION: Our patient had a history of repetitive microtraumas combined with a long second metatarsal bone and altered forefoot kinematics. Initially, because of the low frequency of the disease and lack of knowledge about it, even among general orthopaedic surgeons, the infraction was not diagnosed. However, the radiological characteristics of the lesion, combined with intra-operative observation and histological exams associated with the medical history and clinical exam of the patient, revealed a disease compatible with Freiberg's syndrome. A closing-wedge osteotomy, performed by using a straight burr, appeared to be the most correct treatment. CONCLUSION: This case shows how Freiberg's infraction can pass unrecognized or underestimated and how dorsal closing-wedge osteotomy can be an efficient surgical treatment.
RESUMEN
INTRODUCTION: Freiberg infraction is a relatively rare osteochondrosis of the metatarsal head. The etiology of Freiberg infraction is poorly understood but likely involves factors such as, repetitive trauma and vascular compromise. When discovered early, Freiberg infraction can be cured with conservative measures but late presentations require surgical intervention. We present a case of stage V Freiberg infraction in a Division I collegiate tennis player that responded to conservative treatment. CASE REPORT: A 20 year old female tennis player presented with worsening of her chronic foot pain. She had tenderness to palpation and diminished range of motion at the second metatarsophalangeal joint. Radiographs revealed late stage Freiberg infraction of the second metatarsal. This patient's pain was successfully treated with conservative measures; prolonging her collegiate tennis career. CONCLUSION: Surgical intervention is required for definitive treatment of late stage Freiberg infraction. Conservative treatment can be effective in prolonging the athlete's career.
RESUMEN
Pain in the second metatarsophalangeal joint (MTPJ) is a complaint frequently encountered by foot and ankle specialists. The pathology associated with this joint is often painful and debilitating for the patient. In the past, typical treatment protocols for second MTPJ pathology were aimed at relief of patient symptoms. Conservative treatment and offloading devices have historically dominated treatment options for the clinician. However, recent surgical techniques and procedures have been developed to correct the mechanical and structural defects that can affect this joint. The aim of this review was to outline recent developments and treatment options for common second MTPJ pathologies.
Asunto(s)
Articulación Metatarsofalángica/patología , Articulación Metatarsofalángica/cirugía , Metatarso/anomalías , Procedimientos Ortopédicos/métodos , Osteocondritis/congénito , Analgésicos/uso terapéutico , Artralgia/diagnóstico , Artralgia/etiología , Femenino , Estudios de Seguimiento , Humanos , Inestabilidad de la Articulación/diagnóstico por imagen , Inestabilidad de la Articulación/patología , Inestabilidad de la Articulación/cirugía , Masculino , Articulación Metatarsofalángica/diagnóstico por imagen , Metatarso/diagnóstico por imagen , Metatarso/patología , Metatarso/cirugía , Osteocondritis/diagnóstico por imagen , Osteocondritis/patología , Osteocondritis/cirugía , Osteocondritis/terapia , Dimensión del Dolor , Modalidades de Fisioterapia , Radiografía , Rango del Movimiento Articular/fisiología , Procedimientos de Cirugía Plástica/métodos , Recuperación de la Función , Medición de Riesgo , Índice de Severidad de la Enfermedad , Resultado del TratamientoRESUMEN
PURPOSE: We compared the results of three surgical procedures of the old neglected Freiberg's disease that was managed with metatarsal head reshaping, metatarsal head resection, and dorsal closing wedge osteotomy. MATERIALS AND METHODS: From march 1996 to July 2002, five cases in six patients whose metatarsal head collapse already progressed underwent operative treatment. We compared the operative results in the view point of the radiographic follow-up and lesser toe metatrasophalangeal joint scale of AOFAS. RESULTS: There were no further joint destruction and loose body formation. Also, lesser toe metatrasophalangeal joint scale of AOFAS improved from average score, 38.5 (range 22~49) of preoperative one to average score, 86.6 (range, 72~100). Especially, the 2 cases that underwent dorsal closing wedge osteotomy showed most favorable result and the 2 cases with metatarsal resection showed next favorable result. The 2 cases with intra-articular loose body removal and metatarsal reshaping showed the least effective result among three operative methods. CONCLUSION: Our Operative experiences of old neglected Freiberg's disease were all satisfactory irrespective of operative options and dorsal closing wedge osteotomy was thought to be most effective method.