- Email: [email protected]
A neglected plantar dislocation of first metatarsophalangeal joint: a case report
Foot and Ankle Surgery 10 (2004) 227–230 www.elsevier.com/locate/fas
Case report
A neglected plantar dislocation of first metatarsophalangeal joint: a case report Sezgin Sarban*, Orhan Erol, Mithat Yazar, Ugur E. Isikan Department of Orthopaedic Surgery, Faculty of Medicine, Harran University, Emniyet Caddesi Kultur Sokak Sembol Apt. 17/10, Yenisehir, 63000 Sanliurfa, Turkey Received 16 September 2003; revised 16 August 2004; accepted 7 September 2004
Abstract We describe a 17-year-old male patient with bilateral postaxial polydactily and traumatic plantar dislocation of the right first metatarsophalangeal joint which was untreated for three months. He had discomfort on the lateral side of both forefoots and a painful deformation on the right great toe. The patient was treated with amputation of both supernumerary toes and open reduction of the first metatarsophalangeal joint by means of medial and dorsal first web space insicions and intramedullary K-wire fixation. A short leg walking cast was applied to the right limb. After six weeks, the cast and the K-wire were removed and physiotherapy of the joint was started. Twenty months after surgery no instability but mild osteoarthritic changes were encountered at the joint. q 2004 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. Keywords: Foot; Metatarsophalangeal joint; Dislocation
1. Introduction Traumatic dislocations of first metatarsophalangeal joint (MTPJ) is an uncommon pathology. Jahss [1] reported 14 cases in 1980. In literature, we found 71 cases [2–14]. Of these, 66 were dorsal dislocation, two were dorsomedial, one was medial, one was plantar and one was lateral. Most of these dislocations had been treated conservatively. Surgical intervention had been recommended for nonreducible cases. Jahss [15] divided dorsal MTPJ dislocations of the great toe into three types (I, IIA, and IIB). In type I, intersesamoid ligaments and sesamoids are intact; in type IIA, there are sesamoid dislocations (with disruption of intersesamoid ligaments); and in type IIB, there are fractures of the sesamoids. Type I dislocation is nonreducible by closed manipulation. Closed reduction is usually successful in type II dislocations, but when the sesamoid is fractured, the distal fragment usually requires excision. In 1994, Garcia Mata * Corresponding author. Tel.: C90 414 314 2825; fax: C90 414 315 1181. E-mail address: [email protected] (S. Sarban).
et al. [5] proposed that each of these three types can be with or without associated dislocation of sesamoid complex (SC or SK); in the type IS-, sesamoids are in place; in type ISC, sesamoids are dislocated dorsally. Copeland and Kanat [3] reported a case in which there was an avulsion fracture of the fibular sesamoid and complete disruption of the intersesamoidal ligament. They proposed an additional type IIC dislocation to Jahss’ classification. In cases of ruptured medial collateral ligament, in addition to classification, Bousselmame et al. [2] suggested the supplementation of type III for pure lateral dislocations and type IL or IIL for dorso-lateral dislocations. Plantar dislocation of the first MTPJ is an extremely rare injury. In this type of injury, intersesamoid ligament and sesamoids are intact and closed reduction is sufficient nearly in all patients. Garcia Mata et al. [6] reported a case which occurred in a lactating lady following minor trauma. It was treated successfully by closed reduction. We report a case of neglected irreducible plantar dislocation of first MTPJ with partially ruptured medial collateral ligament and dorsomedial capsule. This is the second case of dislocated hallux plantarly and the first case treated by open surgery in literature.
1268-7731/$ - see front matter q 2004 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.fas.2004.09.001
228
S. Sarban et al. / Foot and Ankle Surgery 10 (2004) 227–230
Fig. 1. Initial presentation. (A) Anteroposterior photograph shows plantar flexed hallux on the first metatarsal and postaxial polidactiliy of the both foot. (B) Lateral view of the right foot, note plantar flexed position of hallux and planovalgus deformity of the foot.
2. Case report A 17-year-old male was admitted to our outpatient clinic with a deformity and pain on his right foot (Fig. 1). On physical examination mild swelling of the first MTPJ and plantar dislocation of the great toe were evident. In the patient’s history he had a dorsal direct trauma (a heavy object—a stove—fell onto the hyperflexed forefoot in a flexible tennis shoe) to the right first MTPJ three months previously. Radiographs confirmed a plantar–lateral dislocation of the right first MTPJ, bilateral postaxial polydactily and the right rigid pes planovalgus with bony changes (Fig. 2). We planned open reduction. Firstly the MTPJ was exposed through a medial approach. Dorsomedial capsule
Fig. 2. (A) Preoperative anteroposterior and (B) oblique radiographs shows plantar dislocation of the first MTPJ.
had a laxity and medial collateral ligament was partially ruptured on the metatarsal head proximally. The intersesamoidal ligament and the sesamoids were intact but the reduction was blocked by the tightened plantar structures, such as the plantar capsule, adductor hallucis and flexor hallucis longus. So the second dorsolateral first web space approach was performed. Reduction was achieved by performing a tenotomy to the transverse and oblique head of the adductor hallucis, incision to the tightened plantar– lateral capsule and at the last excision of the lateral sesamoid. The long-term reduction stability was provided partially ruptured medial collateral ligament reinsertion and dorsomedial capsule plication. The MTPJ was fixed with a K-wire intramedullary. Both supernumerary toes were amputated through a racquet-shaped incision and tendons were divided near their insertion and sutured to the adjacent tendon to preserve
S. Sarban et al. / Foot and Ankle Surgery 10 (2004) 227–230
229
Fig. 3. (A) Anteroposterior photograph of the both feet made one year after operation, shows normally aligned first MTPJ and good clinic outcome. (B) Lateral view of the right foot, note aligned position of hallux.
function. The capsule and ligaments were reconstructed to prevent malalignment of the neighbouring toes. After the operations he was mobilised with partial weight-bearing of right lower extremity for six weeks using a short leg cast to prevent dorsal and plantar flexion of the first MTPJ. In the sixth week of the operation, short leg cast and K-wire were extracted and rehabilitation of the joint was started. One year later, he wears shoes with comfort and plays football with only occasional minor discomfort (Fig. 3). The range of motion of the MTPJ was 308 of dorsiflexion and 608 of plantar flexion. Twenty months after surgery mild osteoarthritic changes with narrowing and limitation of the first MTPJ were encountered (Fig. 4). The clinical result was good and the patient was satisfied with the operation.
3. Discussion Dislocation of the first MTPJ has been reported with motor vehicle accidents, falls from heights and athletic injuries. The anatomical structures of the joint,
Fig. 4. X-ray findings at the 20 months follow-up. Good alignment of the joint is maintained with only mild osteoarthrosis. (A) Anteroposterior; (B) lateral X-rays of both foots.
the direction and mechanics of the trauma and the type of shoe worn at the moment of the trauma all affect the type of the first MTPJ dislocation which can occur [2,8,13]. The first MTPJ is a condylar articulation and the joint capsule has two strong collateral ligaments on both medial and lateral sides. The capsule is reinforced by the extansor hallucis longus dorsally and by the fibrocartilaginous plate with two sesamoids plantarly. The lateral edge of this plate is in continuity with the deep transverse metatarsal ligament. The abductor hallucis tendon and the medial head of the flexor hallucis brevis are attached to the tibial sesamoid, while the tendons of the lateral head of the flexor hallucis brevis and the adductor hallucis insert on the fibular sesamoid [16].
230
S. Sarban et al. / Foot and Ankle Surgery 10 (2004) 227–230
According to Jahss [15], type I and II injuries are dorsal dislocations and caused by an axial load applied to the plantar aspect of the great toe while the first MTPJ is in a hyperdorsiflexed position. While the sesamoid complex is intact in type I, intersesamoid ligament rupture (IIA) or a fracture of either the tibial or fibular sesamoid (IIB) may occur in type II. Copeland and Kanat [3] also described IIC as a combination of Jahss type IIA and IIB. Massari et al. [12] and Bousselmame et al. [2] reported pure medial and lateral dislocations which were unclassified. As the number of cases increases, it is observed that Jahss’ original classification gets insufficient. The first plantar dislocation of the MTPJ was reported by Garcia Mata et al. [6] which occurred in a lactating lady following minor trauma. That case was treated by closed reduction. We report an example of incomplete dislocation of the first MTPJ which occurred in a young man with other foot abnormalities. Admission of the patient to our hospital was three months later after the trauma. Closed reduction failed so open reduction with fibular sesamoid excision was required. Because of the late admission, tightened plantar structures and ruptured dorsomedial capsuloligamentous structures made the closed reduction impossible. We used two incisions; medial approach was performed for plication because of the laxity of the medial capsule and reinsertion of ruptured medial collateral ligament. Dorsal first web space approach was applied for adductor hallucis tenotomy and fibular sesamoidectomy. This is the first case in literature which was treated by open reduction of the plantar dislocation of the MTPJ of the great toe. In this case, we were in conflict with doing primary arthrodesis or open reduction of the first MTPJ because of the late admission. The decision of open reduction was based on the normal cartilage of the first metatarsal head in preoperative ultrasonography and under direct vision at the operation. The follow-up examination at 20 months revealed minimal pain with gait especially in push-off period. The radiographic examination at 20 months showed mild osteoarthrosis of the joint. We believed that the reasons for relatively good clinical outcome were the amputation of the supernumerary toes and the good alignment of the MTPJ. In conclusion, isolated medial, lateral and plantar dislocations of the first MTPJ represent significant
capsuloligamentous avulsion and they are in unclassified groups. For this reason, we suggest that Jahss’ classification must be revised, considering not only sagital plane lesions, but also coronal plane lesions to optimize the treatment.
References [1] Jahss MH. Traumatic dislocations of the first metatarsophalangeal joint. Foot Ankle 1980;1:15–21. [2] Bousselmame N, Rachid K, Lazrak K, Galuia F, Taobane H, Moulay I. Nouvelles varie´te´s de luxations me´tatarso-phalangiennes du gros orteil: les luxations late´rales. Rev Chir Orthop Reparatrice Appar Mot 2001;87:162–9. [3] Copeland CL, Kanat IO. A new classification for traumatic dislocations of the first metatarsophalangeal joint: type IIC. J Foot Surg 1991;30:234–7. [4] Garcia Mata S, Ovejero AH, Grande MM. Dorsal dislocation of the first metatarsophalangeal joint: a case report. Int Orthop 1988;12: 237–8. [5] Garcia Mata S, Hidalgo A, Grande MM. Dorsal dislocation of the first metatarsophalangeal joint. Int Orthop 1994;18:236–9. [6] Garcia Mata S, Ovejero AH, Grande MM. Plantar dislocation of the first metatarsophalangeal joint during lactation: a case report. Int Orthop 1995;19:65–6. [7] Good JJ, Weinfeld GD, Yu GV. Fracture-dislocation of the first metatarsophalangeal joint: open reduction through a medial incisional approach. J Foot Ankle Surg 2001;40:311–7. [8] Hussain A. Dislocation of the first metatarsophalangeal joint with fracture of fibular sesamoid: a case report. Clin Orthop 1999;359: 209–12. [9] Killian FJ, Carpenter BB, Mostone E. Dorsal dislocation of the first metatarsophalangeal joint. J Foot Ankle Surg 1997;36:131–5. [10] Lantor H, Borovoy MA. A new classification of the first metatarsophalangeal joint dislocations (Type IB). J Foot Surg 1987;26:75–7. [11] Lewis AG, DeLee JC. Type I complex dislocation of the first metatarsophalangeal joint: open reduction through a dorsal approach. J Bone Joint Surg 1984;66A:1120–3. [12] Massari L, Ventre T, Larillo A. Atypical medial dislocation of the first metatarsophalangeal joint. Foot Ankle Int 1998;19:624–6. [13] Miki T, Yamamuro T, Kitai T. An irreducible dislocation of great toe: report of two cases and review of the literature. Clin Orthop 1988;230: 200–6. [14] Nabarro MN, Powell J. Dorsal dislocation of the metatarsophalangeal joint of the great toe: a case report. Foot Ankle Int 1995;16:75–8. [15] Jahss MH, editor. Disorders of the foot and ankle. Philadelphia: Saunders; 1992. [16] Brunet JA. Pathomechanics of complex dislocations of the first metatarsophalangeal joint. Clin Orthop 1996;332:126–31.
Case report
A neglected plantar dislocation of first metatarsophalangeal joint: a case report Sezgin Sarban*, Orhan Erol, Mithat Yazar, Ugur E. Isikan Department of Orthopaedic Surgery, Faculty of Medicine, Harran University, Emniyet Caddesi Kultur Sokak Sembol Apt. 17/10, Yenisehir, 63000 Sanliurfa, Turkey Received 16 September 2003; revised 16 August 2004; accepted 7 September 2004
Abstract We describe a 17-year-old male patient with bilateral postaxial polydactily and traumatic plantar dislocation of the right first metatarsophalangeal joint which was untreated for three months. He had discomfort on the lateral side of both forefoots and a painful deformation on the right great toe. The patient was treated with amputation of both supernumerary toes and open reduction of the first metatarsophalangeal joint by means of medial and dorsal first web space insicions and intramedullary K-wire fixation. A short leg walking cast was applied to the right limb. After six weeks, the cast and the K-wire were removed and physiotherapy of the joint was started. Twenty months after surgery no instability but mild osteoarthritic changes were encountered at the joint. q 2004 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. Keywords: Foot; Metatarsophalangeal joint; Dislocation
1. Introduction Traumatic dislocations of first metatarsophalangeal joint (MTPJ) is an uncommon pathology. Jahss [1] reported 14 cases in 1980. In literature, we found 71 cases [2–14]. Of these, 66 were dorsal dislocation, two were dorsomedial, one was medial, one was plantar and one was lateral. Most of these dislocations had been treated conservatively. Surgical intervention had been recommended for nonreducible cases. Jahss [15] divided dorsal MTPJ dislocations of the great toe into three types (I, IIA, and IIB). In type I, intersesamoid ligaments and sesamoids are intact; in type IIA, there are sesamoid dislocations (with disruption of intersesamoid ligaments); and in type IIB, there are fractures of the sesamoids. Type I dislocation is nonreducible by closed manipulation. Closed reduction is usually successful in type II dislocations, but when the sesamoid is fractured, the distal fragment usually requires excision. In 1994, Garcia Mata * Corresponding author. Tel.: C90 414 314 2825; fax: C90 414 315 1181. E-mail address: [email protected] (S. Sarban).
et al. [5] proposed that each of these three types can be with or without associated dislocation of sesamoid complex (SC or SK); in the type IS-, sesamoids are in place; in type ISC, sesamoids are dislocated dorsally. Copeland and Kanat [3] reported a case in which there was an avulsion fracture of the fibular sesamoid and complete disruption of the intersesamoidal ligament. They proposed an additional type IIC dislocation to Jahss’ classification. In cases of ruptured medial collateral ligament, in addition to classification, Bousselmame et al. [2] suggested the supplementation of type III for pure lateral dislocations and type IL or IIL for dorso-lateral dislocations. Plantar dislocation of the first MTPJ is an extremely rare injury. In this type of injury, intersesamoid ligament and sesamoids are intact and closed reduction is sufficient nearly in all patients. Garcia Mata et al. [6] reported a case which occurred in a lactating lady following minor trauma. It was treated successfully by closed reduction. We report a case of neglected irreducible plantar dislocation of first MTPJ with partially ruptured medial collateral ligament and dorsomedial capsule. This is the second case of dislocated hallux plantarly and the first case treated by open surgery in literature.
1268-7731/$ - see front matter q 2004 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.fas.2004.09.001
228
S. Sarban et al. / Foot and Ankle Surgery 10 (2004) 227–230
Fig. 1. Initial presentation. (A) Anteroposterior photograph shows plantar flexed hallux on the first metatarsal and postaxial polidactiliy of the both foot. (B) Lateral view of the right foot, note plantar flexed position of hallux and planovalgus deformity of the foot.
2. Case report A 17-year-old male was admitted to our outpatient clinic with a deformity and pain on his right foot (Fig. 1). On physical examination mild swelling of the first MTPJ and plantar dislocation of the great toe were evident. In the patient’s history he had a dorsal direct trauma (a heavy object—a stove—fell onto the hyperflexed forefoot in a flexible tennis shoe) to the right first MTPJ three months previously. Radiographs confirmed a plantar–lateral dislocation of the right first MTPJ, bilateral postaxial polydactily and the right rigid pes planovalgus with bony changes (Fig. 2). We planned open reduction. Firstly the MTPJ was exposed through a medial approach. Dorsomedial capsule
Fig. 2. (A) Preoperative anteroposterior and (B) oblique radiographs shows plantar dislocation of the first MTPJ.
had a laxity and medial collateral ligament was partially ruptured on the metatarsal head proximally. The intersesamoidal ligament and the sesamoids were intact but the reduction was blocked by the tightened plantar structures, such as the plantar capsule, adductor hallucis and flexor hallucis longus. So the second dorsolateral first web space approach was performed. Reduction was achieved by performing a tenotomy to the transverse and oblique head of the adductor hallucis, incision to the tightened plantar– lateral capsule and at the last excision of the lateral sesamoid. The long-term reduction stability was provided partially ruptured medial collateral ligament reinsertion and dorsomedial capsule plication. The MTPJ was fixed with a K-wire intramedullary. Both supernumerary toes were amputated through a racquet-shaped incision and tendons were divided near their insertion and sutured to the adjacent tendon to preserve
S. Sarban et al. / Foot and Ankle Surgery 10 (2004) 227–230
229
Fig. 3. (A) Anteroposterior photograph of the both feet made one year after operation, shows normally aligned first MTPJ and good clinic outcome. (B) Lateral view of the right foot, note aligned position of hallux.
function. The capsule and ligaments were reconstructed to prevent malalignment of the neighbouring toes. After the operations he was mobilised with partial weight-bearing of right lower extremity for six weeks using a short leg cast to prevent dorsal and plantar flexion of the first MTPJ. In the sixth week of the operation, short leg cast and K-wire were extracted and rehabilitation of the joint was started. One year later, he wears shoes with comfort and plays football with only occasional minor discomfort (Fig. 3). The range of motion of the MTPJ was 308 of dorsiflexion and 608 of plantar flexion. Twenty months after surgery mild osteoarthritic changes with narrowing and limitation of the first MTPJ were encountered (Fig. 4). The clinical result was good and the patient was satisfied with the operation.
3. Discussion Dislocation of the first MTPJ has been reported with motor vehicle accidents, falls from heights and athletic injuries. The anatomical structures of the joint,
Fig. 4. X-ray findings at the 20 months follow-up. Good alignment of the joint is maintained with only mild osteoarthrosis. (A) Anteroposterior; (B) lateral X-rays of both foots.
the direction and mechanics of the trauma and the type of shoe worn at the moment of the trauma all affect the type of the first MTPJ dislocation which can occur [2,8,13]. The first MTPJ is a condylar articulation and the joint capsule has two strong collateral ligaments on both medial and lateral sides. The capsule is reinforced by the extansor hallucis longus dorsally and by the fibrocartilaginous plate with two sesamoids plantarly. The lateral edge of this plate is in continuity with the deep transverse metatarsal ligament. The abductor hallucis tendon and the medial head of the flexor hallucis brevis are attached to the tibial sesamoid, while the tendons of the lateral head of the flexor hallucis brevis and the adductor hallucis insert on the fibular sesamoid [16].
230
S. Sarban et al. / Foot and Ankle Surgery 10 (2004) 227–230
According to Jahss [15], type I and II injuries are dorsal dislocations and caused by an axial load applied to the plantar aspect of the great toe while the first MTPJ is in a hyperdorsiflexed position. While the sesamoid complex is intact in type I, intersesamoid ligament rupture (IIA) or a fracture of either the tibial or fibular sesamoid (IIB) may occur in type II. Copeland and Kanat [3] also described IIC as a combination of Jahss type IIA and IIB. Massari et al. [12] and Bousselmame et al. [2] reported pure medial and lateral dislocations which were unclassified. As the number of cases increases, it is observed that Jahss’ original classification gets insufficient. The first plantar dislocation of the MTPJ was reported by Garcia Mata et al. [6] which occurred in a lactating lady following minor trauma. That case was treated by closed reduction. We report an example of incomplete dislocation of the first MTPJ which occurred in a young man with other foot abnormalities. Admission of the patient to our hospital was three months later after the trauma. Closed reduction failed so open reduction with fibular sesamoid excision was required. Because of the late admission, tightened plantar structures and ruptured dorsomedial capsuloligamentous structures made the closed reduction impossible. We used two incisions; medial approach was performed for plication because of the laxity of the medial capsule and reinsertion of ruptured medial collateral ligament. Dorsal first web space approach was applied for adductor hallucis tenotomy and fibular sesamoidectomy. This is the first case in literature which was treated by open reduction of the plantar dislocation of the MTPJ of the great toe. In this case, we were in conflict with doing primary arthrodesis or open reduction of the first MTPJ because of the late admission. The decision of open reduction was based on the normal cartilage of the first metatarsal head in preoperative ultrasonography and under direct vision at the operation. The follow-up examination at 20 months revealed minimal pain with gait especially in push-off period. The radiographic examination at 20 months showed mild osteoarthrosis of the joint. We believed that the reasons for relatively good clinical outcome were the amputation of the supernumerary toes and the good alignment of the MTPJ. In conclusion, isolated medial, lateral and plantar dislocations of the first MTPJ represent significant
capsuloligamentous avulsion and they are in unclassified groups. For this reason, we suggest that Jahss’ classification must be revised, considering not only sagital plane lesions, but also coronal plane lesions to optimize the treatment.
References [1] Jahss MH. Traumatic dislocations of the first metatarsophalangeal joint. Foot Ankle 1980;1:15–21. [2] Bousselmame N, Rachid K, Lazrak K, Galuia F, Taobane H, Moulay I. Nouvelles varie´te´s de luxations me´tatarso-phalangiennes du gros orteil: les luxations late´rales. Rev Chir Orthop Reparatrice Appar Mot 2001;87:162–9. [3] Copeland CL, Kanat IO. A new classification for traumatic dislocations of the first metatarsophalangeal joint: type IIC. J Foot Surg 1991;30:234–7. [4] Garcia Mata S, Ovejero AH, Grande MM. Dorsal dislocation of the first metatarsophalangeal joint: a case report. Int Orthop 1988;12: 237–8. [5] Garcia Mata S, Hidalgo A, Grande MM. Dorsal dislocation of the first metatarsophalangeal joint. Int Orthop 1994;18:236–9. [6] Garcia Mata S, Ovejero AH, Grande MM. Plantar dislocation of the first metatarsophalangeal joint during lactation: a case report. Int Orthop 1995;19:65–6. [7] Good JJ, Weinfeld GD, Yu GV. Fracture-dislocation of the first metatarsophalangeal joint: open reduction through a medial incisional approach. J Foot Ankle Surg 2001;40:311–7. [8] Hussain A. Dislocation of the first metatarsophalangeal joint with fracture of fibular sesamoid: a case report. Clin Orthop 1999;359: 209–12. [9] Killian FJ, Carpenter BB, Mostone E. Dorsal dislocation of the first metatarsophalangeal joint. J Foot Ankle Surg 1997;36:131–5. [10] Lantor H, Borovoy MA. A new classification of the first metatarsophalangeal joint dislocations (Type IB). J Foot Surg 1987;26:75–7. [11] Lewis AG, DeLee JC. Type I complex dislocation of the first metatarsophalangeal joint: open reduction through a dorsal approach. J Bone Joint Surg 1984;66A:1120–3. [12] Massari L, Ventre T, Larillo A. Atypical medial dislocation of the first metatarsophalangeal joint. Foot Ankle Int 1998;19:624–6. [13] Miki T, Yamamuro T, Kitai T. An irreducible dislocation of great toe: report of two cases and review of the literature. Clin Orthop 1988;230: 200–6. [14] Nabarro MN, Powell J. Dorsal dislocation of the metatarsophalangeal joint of the great toe: a case report. Foot Ankle Int 1995;16:75–8. [15] Jahss MH, editor. Disorders of the foot and ankle. Philadelphia: Saunders; 1992. [16] Brunet JA. Pathomechanics of complex dislocations of the first metatarsophalangeal joint. Clin Orthop 1996;332:126–31.