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Fifth Metatarsal Osteotomy for Correction of Bunionette Deformity

Indications Wide forefoot with symptomatic fifth metatarsal (5MT) head and medial deviation of fifth toe Failure of nonoperative treatment (shoe modifications) Weight-bearing anteroposterior (AP) foot radiograph demonstrating a widened fourth-fifth intermetatarsal angle (4/5 IMA) Examination/Imaging Wide forefoot Symptomatic 5MT head and medial deviation of fifth toe Widened 4/5 IMA (type II or type III bunionette deformity) on a weight-bearing AP foot radiograph ( Fig. 15.1 )…

Forefoot Reconstruction for Rheumatoid Disease

Indications Chronic pain and deformity of the forefoot from rheumatoid arthritis Recurrent ulceration Failure of nonoperative measures, including shoe modification and orthotics Indications Pitfalls Active infection or ulceration should be eradicated prior to surgery. Severe skin fragility may preclude operative intervention. Medications that interfere with bone and wound healing, especially methotrexate and tumor necrosis factor antagonists, should be stopped 2 weeks prior to surgery. They can…

Arthroscopic Fusion of the Great Toe

Indications End-stage arthritis of the first metatarsophalangeal (MTP) joint End-stage arthritis of the sesamoid to metatarsal head articulation Disruption of the plantar plate Gouty arthritis Indications Pitfalls Arthroscopic fusion is limited to minimal deformity as an open release of soft-tissue contractures would prevent the joint being appropriately exposed. Indications Controversies Some deformity can be corrected with an arthroscopic fusion, and some authors have advocated using arthroscopic…

Arthrodesis of the Great Toe Metatarsophalangeal Joint

Indications Chronic joint pain from advanced arthritis Severe deformity that limits activity or footwear Controversies Arthrodesis is the most commonly performed procedure for advanced symptomatic arthritis or severe deformity of the great toe. The end result is highly predictable, alleviates symptoms, and restores excellent function. Unreliable surgical options include resection arthroplasty, hemiarthroplasty, or total joint arthroplasty. A polyvinyl alcohol implant may be considered in certain specific…

Polyvinyl Alcohol Hemiarthroplasty for First Metatarsophalangeal Arthritis

Indications Symptomatic first metatarsophalangeal (MTP) joint arthritis Maintenance of functional motion of the first MTP joint Minimal first ray deformity (valgus, varus, elevation) Arthritis of appropriate severity (K–L grades III or IV) Indications Pitfalls A plantar flexed first MTP joint will likely not be able to move into dorsiflexion Sepsis Charcot arthropathy with risk of bone collapse Bone loss unable to support the implant Indications Controversies…

Interpositional Arthroplasty of the Great Toe

Indications Arthritis of the first metatarsophalangeal (MTP) joint beyond cheilectomy treatment Concomitant arthritis of the sesamoid bones Failed cheilectomy Indications Pitfalls Very stiff joints may be better fused; do not expect as much motion. Infected joints may need a two-stage procedure. Hallux varus or other severe instabilities may require simultaneous ligamentous reconstruction (see Stein, Miller article). Indications Controversies Very stiff joint may do better with fusion…

Hallux Rigidus: Cheilectomy With and Without a Dorsiflexion Phalangeal Osteotomy

Indications Cheilectomy of the first metatarsophalangeal joint (MTPJ) is indicated for painful hallux rigidus with impinging bone spurs. Most frequently indicated for grade I and grade II hallux rigidus, but may also be utilized for grade III. Grade I includes mild to moderate osteophyte formation with joint space preservation. Grade II includes moderate osteophyte formation with joint space narrowing. Grade III includes extensive osteophyte formation with…

Arthroscopy of the Great Toe

Indications Loose bodies Hallux valgus: synovitis Hallux valgus: lateral release Turf toe: assessment of plantar plate Sesamoid to metatarsal head arthritis Gout Dorsal osteophytes Hallux rigidus Chondral defect Arthroscopic first metatarsophalangeal (MTP) fusion Synovitis Diagnostic arthroscopy for recurrent pain or swelling localized to the MTP joint Arthrofibrosis Osteochondral defects Pigmented villonodular synovitis Ganglion excision Indications Pitfalls For some indications the surgery can be combined with an…

Correction of Acquired Hallux Varus

Indications Pitfalls Hallux varus must be reducible. Malunion of the metatarsal or proximal phalanx may preclude a simple soft-tissue correction. A negative intermetatarsal angle may require correction. Consider a fusion for an arthritic joint. Indications Controversies There are no long-term studies published on the outcome of this procedure. Treatment Options Stretching out the shoe toe box can diminish irritation of the toe. Several other procedures exist…

Revision Hallux Valgus Surgery

Indications Ongoing pain symptomatic enough to merit surgery Recurrent hallux valgus deformity Second metatarsalgia or overload Elevated first ray Plantar flexed first ray Hallux varus Avascular necrosis of the first metatarsal (MT) head Nonunion of osteotomy or arthrodesis Indications Pitfalls Understanding the cause of symptoms is paramount to selecting an appropriate procedure. Understanding why the index procedure failed (i.e., technical, patient factors, complications) is critical to…

Proximal Long Oblique (Ludloff) First Metatarsal Osteotomy With Distal Soft-Tissue Procedure

Indications Symptomatic moderate to severe hallux valgus (first/second intermetatarsal angle [1/2 IMA] >15°) failing nonoperative treatment Indications Pitfalls Contraindications to surgical correction of hallux valgus deformity: peripheral vascular disease and peripheral neuropathy Contraindication to surgical correction of hallux valgus with a metatarsal osteotomy: hallux rigidus (degenerative joint disease of the first metatarsophalangeal [1MTP] joint) Relative contraindications to the Ludloff osteotomy: narrow first metatarsal (1MT; limited surface…

Modified “Lapidus” Procedure: Tarsometatarsal Corrective Osteotomy and Fusion With First Metatarsophalangeal Joint Correction and Realignment

Indications Moderate to severe foot deformity, including Hallux valgus with metatarsus primus varus Hypermobility of the medial column Pes plano abductovalgus Examination/Imaging Physical Examination Upon weight bearing, hallux valgus is observed toward a more severe deformity. Proper examination of the foot often will reveal associated hypermobility of the medial column and an equinus contracture of the gastrocnemius. There may also be flatfoot deformity (pes plano abductovalgus).…

Hallux Valgus Correction With Metatarsal Opening Wedge and Proximal Phalangeal Osteotomies

Indications Painful hallux valgus deformity Failure of shoe modification Symptoms that interfere with daily activities A moderate to severe bunion deformity, with an intermetatarsal angle of ≥13° Hallux interphalangeus (HI) that causes great toe impingement on the second toe Indications Pitfalls Moderate to severe arthritic changes of the joint are a contraindication to hallux valgus surgery. Blood supply to the foot is compromised. Ulceration over the…

Scarf Osteotomy for Correction of Hallux Valgus

Indications Objective Indications Moderate to severe hallux valgus deformities with Increased hallux valgus angle (HVA) ≤50° Increased intermetatarsal angle (IMA) ≤20° Increased distal metatarsal articular angle (DMAA) ≤10° Hallux valgus revision surgery for recurrence (Bock, 2009) Bunionette deformity of fifth metatarsal (type 3, increased fourth–fifth IMA) Modular corrections are feasible via the great versatility of the Scarf osteotomy Lateralization of head-shaft fragment to reduce IMA Transverse…

Hallux Valgus Correction With Modified Chevron Osteotomy

Indications Painful hallux valgus deformity Failure of shoe modification Symptoms that interfere with daily activities A mild to moderate deformity (hallux valgus angle <30º; intermetatarsal angle [IMA] <13–15°) Patients with a high distal metatarsal articular angle (DMAA) require a chevron osteotomy with the addition of a closing wedge Pitfalls Moderate arthritic changes of the joint are usually a contraindication to hallux valgus surgery. A compromised blood…

Knee Arthroplasty and Patellofemoral Rating Systems

Total Knee Arthroplasty Outcome Instruments Critical Points Total Knee Arthroplasty Outcome Instruments Lack of consensus exists regarding which instrument or rating system should be selected, due in part to the moderate to poor quality of investigations that determined their psychometric properties. UCLA activity rating scale: 10 levels ranging from wholly inactive and dependent on others to regular participation in impact sports. Superior to Tegner and Marx…

Articular Cartilage Rating Systems

Introduction Many grading systems have been proposed to classify lesions of the articular cartilage in the knee joint at arthroscopy; however, only a few are commonly used in modern orthopedic literature ( Table 44-1 ). The systems published in the 1960s and 1970s introduced grading schemes for lesions located only in the patellofemoral joint and documented the most frequent locations of damage in this compartment. The…

Rating of Athletic and Daily Functional Activities: Knee-Specific Scales and Global Outcome Instruments

Introduction This chapter reviews commonly used scales and outcome instruments that rate athletic and daily functional activities for a variety of knee injuries and disorders in younger active patients. The instruments are analyzed according to their strengths and potential biases as well as their measured reliability, validity, and responsiveness properties. Scales from the Cincinnati Knee Rating System (CKRS) and the International Documentation Committee Rating (IKDC) System…

International Knee Documentation Committee Rating System

Introduction To provide a comprehensive analysis of the knee condition and the effect of a treatment protocol on a knee injury or disorder, authors have suggested that rating systems measure a variety of symptoms, sports and daily activity functions, and objective findings. To our knowledge, only three knee-specific rating systems are available that measure all of these factors and have established psychometric properties of reliability, validity…

Cincinnati Knee Rating System

Introduction Critical Points Introduction Many knee-specific scales and rating systems have been published in the last decade with acceptable psychometric properties for a variety of diagnoses. Scales rate specific activities, such as sports or daily functions. Rating systems provide a comprehensive analysis of the knee condition and its impact on activity and function after the treatment protocol under study. Only three knee rating systems are currently…