SURGERY OF THE HALLUX

VOLUME 10 • NUMBER 1 • MARCH 2005 v

CONTENTS

Preface xiV. James Sammarco

The First Metatarsal Bone Under Loading Conditions: A Finite Element Analysis 1K.-H. Kristen, K. Berger, C. Berger, W. Kampla, W. Anzböck, and S.H. Weitzel

An individual-based, three-dimensional finite element model ofthe first metatarsal (MT I) bone was created with fine CT. Thethree-dimensional model of the bone was fixed proximally at themetatarsocuneiform joint and load was applied on the metatarsalhead. Loading conditions were simulated, including muscularforces as described for a normal metatarsophalangeal (MTP) jointduring three typical phases of gait as the combination of the loadin the contact areas of the sesamoid bones and the base of the prox-imal phalanx. The resultant strain and stress distributions withinthe loaded MT I were calculated and visualized with the MTP indifferent positions.

Osteotomies for Hallux Valgus Correction 15Hans-Jörg Trnka

A variety of metatarsal osteotomies has been described since thefirst report by Gernet in 1836. Many of these osteotomies wereabandoned throughout the years. Because one procedure is notcapable of correcting all types of hallux valgus deformities, an algo-rithm, as a guideline, is preferable. This article presents a choice ofmetatarsal osteotomies for correction of hallux deformities basedon clinical and biomechanical research.

First Metatarsal Osteotomy Nonunion and Malunion 35Anand M. Vora and Mark S. Myerson

The purpose of this article is to review our experience with malunionand nonunion of proximal and distal first metatarsal osteotomies and to outline the treatment options when such complications occur.

Management of Soft Tissue Deficiency of the Hallux: Salvage in Trauma, Diabetes, and Following Surgical Complications 55V. James Sammarco

Loss of the hallux can lead to significant gait problems and causedifficult biomechanical problems with weight bearing. Amputationof the first ray should be avoided when possible. Soft tissue defectof the hallux can be particularly difficult to manage because of theabsence of local muscle tissue for coverage. In younger patients,soft tissue loss usually is related to trauma; an understanding of thetechniques that are available for coverage are important to maintainlength and function of the first ray. Diabetic neuropathy and resul-tant ulceration of the hallux or metatarsophalangeal joint is anothercommon cause of soft tissue deficiency that may lead to deep infec-tion and potentially result in amputation. Certain systemic prob-lems, such as inflammatory diseases or gout, can cause significantdegeneration of the local tissues which also can be problematic.Wound dehiscence or loss of skin flaps that are created during sur-gery represent further difficulties that may be encountered. Thisarticle reviews the common causes of amputation of the hallux andthe principles that are necessary for salvage of the digit.

Surgical Treatment of the Hallux Rigidus 75Luciano S. Keiserman, V. James Sammarco, and G. James Sammarco

Numerous surgical procedures are available for the treatment of hallux rigidus. The choice of a particular one depends on the sever-ity of the disease, patient activity level, and expectations about thesurgery. Cheilectomy is recommended for early disease and may beassociated with an osteotomy of the proximal phalanx. For activepatients who have severe hallux rigidus, arthrodesis and biologicinterposition arthroplasties have shown good results. Keller arthro-plasty is reserved for low demand patients; prosthetic replacementsare not recommended at this time.

Joint Replacement in the Hallux Metatarsophalangeal Joint 97Jan-Eric Esway and Stephen F. Conti

Joint replacement of the hallux metatarsophalangeal joint has notenjoyed the same success as hip and knee arthroplasties. Silasticimplants have achieved a high patient satisfactory rate but havecaused many complications, including silicone synovitis and

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lymph node inflammation. Metal and polyethylene hemiarthro-plasties and total toe replacements seem to be more promisingalthough results are preliminary. Problems with these implants seemto be related to soft tissue instability of the joint; patients who havehallux rigidus have more success than patients who have hallux val-gus or rheumatoid arthritis. Severe complications can be treated withremoval and synovectomy or arthrodesis, depending on the lengthand alignment of the foot, as well as the functional demands of thepatients. It would be beneficial to have more data on these implantsso that improvements can be made in design and patient selection.

Avascular Necrosis of the First Metatarsal Head 117William H.B. Edwards

Avascular necrosis of the first metatarsal head is uncommon. It ismost often seen following a distal metatarsal osteotomy for halluxvalgus. In this setting surgery has usually involved extensive peri-articular dissection as well. Although many cases may be subclini-cal, in its most pronounced form it is a powerful cause of failure ofbunion surgery. This article examines the underlying factor con-tributing to this problem as well as its long-term management.

Disorders of the Hallucal Interphalangeal Joint 129Reza Salleh, Andrew Beischer, and William H.B. Edwards

Most clinical presentations of the hallux concern the metatarsopha-langeal joint; however, interphalangeal joint (IPJ) pathology alsomay be clinically significant. This article reviews conditions thatcommonly affect the hallucal IPJ and the appropriate treatment.

The Great Toe Proximal Phalanx Osteotomy: The Final Step of the Bunionectomy 141Louis Samuel Barouk, Pierre Barouk, Bernard Baudet, and Eric Toullec

As the final step of correction of hallux valgus deformity, the greattoe proximal phalanx osteotomy is useful. It is popular in France andthroughout Europe. Our purpose is to distinguish and to describedifferent locations and three types of osteotomies according to therequired final correction of the hallux valgus.

Hypermobility of the First Tarsometatarsal Joint 157Dane K. Wukich, Brian G. Donley, and James J. Sferra

This article discusses hypermobility of the first tarsometatarsal joint.

Technical Considerations in Hallux Metatarsalphalangeal Arthrodesis 167Armen S. Kelikian

Metatarsalphalangeal (MTP) arthrodesis remains the gold standardfor arthritis and salvage of the painful first MTP joint. There is avariety of techniques, approaches, and armamentarium to consider,depending on the clinical presentation and host factors. This articlereviews the author’s personal experience.

Orthotic Management for Disorders of the Hallux 191V. James Sammarco and Ryan Nichols

Most disease conditions that affect the hallux are amenable to con-servative treatment. Most of the literature that addresses the treat-ment of hallux rigidus, bunions, sesamoid problems, and arthritisfocus on surgical management, although operative indications stressthe need for attempted conservative treatment of these processes.This article reviews the technical considerations that are required for successful orthotic management of disease of the first ray.Mechanical terminology and principles of management are reviewedand examples of orthotic prescriptions for specific disease entities are included to facilitate communication between the orthopedist and orthotist.

Index 211

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