FIRST MTPJ: ACHIEVING BETTER OUTCOMES AMERICAN ASSOCIATION FOR WOMEN PODIATRISTS SPEAKER’S TRACK

MODERATOR: APARNA DUGGIRALA, DPM

JENNIFER SPECTOR, DPM

KAREN LANGONE, DPM

ALISON GARTEN, DPM

ELIZABETH DAUGHTRY, DPM

ERIKA SCHWARTZ, DPM

HEATHER RAFAL, DPM

EXCELLENCE IN TREATMENT OF THE FIRST MTPJ:

INTRODUCTION AND PEARLSJENNIFER SPECTOR, DPM, FACFAS CO-VICE PRESIDENT, AAWP

CAFENGIU PODIATRY, MARLTON, NJ

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjhp8rHyujTAhUJbiYKHbo7BhQQjRwIBw&url=http://www.apma.org/workingforyou/EventDetail.cfm?EventID=69885&psig=AFQjCNFEvN_zuArS6khgbGm3xpwCpEhy0Q&ust=1494616236645790

EXCELLENCE IN FIRST MTPJ – AN OVERVIEW

Importance

Gender

Length

Pediatric

Aging

Forensics

Hypermobility

Sesamoids

WHY IS THE FIRST MTPJ COMPLEX SO IMPORTANT?

• 1/3 body weight

• 3 x hindfoot load

• Vital to Windlass

• Different than any other species

(more doming – habitual DF)

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiatO_x_JjUAhUIQSYKHdgDAPgQjRwIBw&url=https://en.wikipedia.org/wiki/First_metatarsal_bone&psig=AFQjCNHnXLDSNai0_V4m-_jQMJV0H4nDvw&ust=1496280351623223

IMPORTANCE/EVOLUTION OF FIRST RAY SEGMENT

Peroneus longus major stabilizing force

Evolutionary migration of PL across foot to increase stabilization

loss of opposable great toe

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjyy9G-_ZjUAhWEbiYKHRWHClMQjRwIBw&url=https://www.pinterest.com/kataliya/advanced-studies-clairvoyance/&psig=AFQjCNFqhEjc7F5el6iBan0Ok7_mErxdTA&ust=1496280438290041

www.seaworld.org

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiYqIrb_ZjUAhVJLSYKHUf4BsUQjRwIBw&url=https://seaworld.org/animal-info/animal-infobooks/gorilla/physical-characteristics&psig=AFQjCNFObiQMCRHk6fa4BLNtHxnLNJvjeA&ust=1496280577520615

GENDER DIFFERENCES IN FIRST MTPJ PATHOLOGY

Females exhibit:

Prevalence HAV

Ligamentous Laxity

First Ray Hypermobility

Articular surface rounder, smaller instability?

(Ferrari, J, et al. 2004)

GENDER DIFFERENCES IN FIRST MTPJ PATHOLOGY

Hallux Valgus in Males

Onset earlier, pain earlier

68% family hx vs females with 35%

Less correlation with footwear

Main intrinsic contributing factor was DMAA

(Nery, et al 2013)

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjM45rUg7bUAhVJ6oMKHbsSC1wQjRwIBw&url=https://www.academyofclinicalmassage.com/valgus-varus-vargus-what-is-it/&psig=AFQjCNEtWbqa3-TAbeksqQHP7LRk0Az9Qg&ust=1497278597731720

FIRST RAY LENGTH AND GENDER

Females shorter metatarsals and phalanges

Hypothesis Males: lever arm needs to be shortened, occurs by transverse

deviation.

Shortening during osteotomy helpful?

(Munuera, et al, 2008)

FIRST RAY LENGTH IMPACT ON FIRST MTPJ

Too long – need to shorten lever

Too short – tripod is violated and weight shifts

Sesamoids too posterior – can functionally shorten

PEDIATRIC AND GENDER DIFFERENCES IN FIRST RAY

F-Scan 61 children 5-16 years old

Females >> peak pressure under hallux

COP more medial

Faster heel strike to first met head load time

No correlation to hypermobility or hallux valgus angle

Reasons unclear?

(Ferrari, J, Watkinson, D. 2005)

AGING AND THE FIRST RAY

Distal metatarsal articular angle increases

1-3 degrees per 10 years of age

Average change 20-60 years old = 4.5 degrees

(El Said, et al. 2006)

Photo: Chopra, et al.

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiR_93hzrvUAhUEID4KHYieB_cQjRwIBw&url=https://www.triadfoot.com/2016/03/07/aging-gracefully-feet-change-age/&psig=AFQjCNFz5mAFBcTsAcBSqntQ4E0DQV-FvQ&ust=1497470559785165https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwi95JGK2J_VAhXKdj4KHSn8ABcQjRwIBw&url=https://www.researchgate.net/figure/274380123_fig1_Fig-1-Radiographic-measurements-in-weight-bearing-position-representing-M1-M2&psig=AFQjCNHTv50l_m1qPGjTPq9W1OcgRCvj-A&ust=1500909051387716

FORENSIC IMPACT OF FIRST RAY

Stature can be estimated from CT of 1st and 2nd metatarsal

Gender can be determined from length and width of 1st metatarsal

Felt to be better method than on the bone measurement

(Rodriguez, et al 2014 and Hishmat, et al 2015)

HYPERMOBILITY

Morton in 1928 – Still controversy

Met-cuneiform hypermobility = >4 degrees saggital, > 8 degrees transverse

Radiographic and clinical measurements and signs

Not as straightforward as it seems?

DEVICES MEASURING HYPERMOBILITY

Singh, et al, 2016

• Klaue – manual force

• Glasoe - quantifiable – screw

mechanism

• EMC - L shaped device on first and

second met

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwj5sbvGhbbUAhVCOyYKHezCDuQQjRwIBw&url=http://www.journals.elsevierhealth.com/article/S1268-7731(15)00089-2/fulltext&psig=AFQjCNGZgY-x4BesPMA7CxfnMjcOBIq-Gg&ust=1497279069399505

HYPERMOBILITY - PITFALLS

Are we too focused on met-cuneiform?

Saffo, et al : 90% first ray motion occurs from cuneiform-navicular, 10% from met-cun

HYPERMOBILITY - PITFALLS

Sesamoid position – we assume medial/lateral deviation

Still in groove?

Rotation in frontal plane – part of hypermobility

True triplanar correction = less ancillary procedures

DON’T FORGET THE FRONTAL PLANE

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjiirvV0LvUAhWBjz4KHatSDQkQjRwIBw&url=http://www.drblakeshealingsole.com/2014/10/fractured-sesamoid-email-advice.html&psig=AFQjCNHuqz4bXNllpFvCnlR9fb7jH-VHFA&ust=1497470995293130

SESAMOID INJURIES/PATHOLOGY

Acute vs chronic

Variations in treatment of fracture – NWB, WB, offloading

When do you perform sesamoidectomy?

Involvement of MTPJ itself cannot be ignored

ORIF?

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjKl6CZ0J_VAhVFaz4KHf7_BxcQjRwIBw&url=http://foot-health-forum.com/index.php?threads/sesamoid-fractured-or-bipartite.95545/&psig=AFQjCNHuJ5AeKK408tmCUMKgEd0qNpYDwA&ust=1500906889535652

ORIF SESAMOID?

www.aofoundation.org

EQUINE ORIF SESAMOID

www.aofoundation.org

ORIF SESAMOID

Pagenstert, G, et al. Techniques in Foot & Ankle Surgery 7(2):107-114 · June 2008

https://www.researchgate.net/journal/1536-0644_Techniques_in_Foot_Ankle_Surgery

WHAT CAN WE LEARN?

Implant, orthotic, shoe R and D (gender/age specific?)

Not just 2D measurements but shape/morphology differences

Forensic value of the first MTPJ

Lack of EBM – especially in hypermobility

Look at entire biomechanical picture

REFERENCES

Bohman, L and Landsman, A. “Emerging Insights on First Ray Hypermobility.” Podiatry Today. 2015 Dec; 28(12)

Christensen, J and Jennings, M. “Normal and Abnormal Function of the First Ray.” Clin Podiatr Med Surg 2009; 26; 355-371.

Chopra, et al. “Characterization of Gait in Female Patients With Moderate to Severe HalluxValgus Deformity.” J Clinical Biomech, March 2015.

El Said, et al. “First Metataral Bone: An Anatomic Study.” Foot and Ankle Int. 2006 Dec; 27(12)

Fernandez, P, et al. “Functional Aspects of Metatarsal Head Shape in Humans, Apes, and Old World Monkeys.” J Human Evolution. 86(2015) 136-146.

Ferrari, J, and Watkinson, D. “Foot Pressure Measurement Differences Between Boys and Girls With Reference to HalluxValgus Deformity and Hypermobility.” Foot and Ankle Int. 2005 Sep; 26(9); 739-747.

Ferrari J, et al. “Size and Shape Difference Between Male and Female Foot Bones.” JAPMA. 2004 Sep; 94(5); 434-452.

Hansen, S. “Introduction The First Metatarsal: It’s Importance In The Human Foot.” Clin Podiatr Med Surg. 2009; 26; 351-354.

Hishmat, A, et al. “Virtual CT Morphometry of Lower Limb Long Bones For Estimation of the Sex and Stature Using Postmortem Japanese Adult Data in Forensic Identification.” Int J Legal Med. 2015; 129; 1173-1182.

Munuera, P, et al. “Length of the first metatarsal and hallux in hallux valgus in the initial stage.” Int Orthop. 2008 Aug; 32(4): 489-495

Myerson MS, et al. “Hypermobility of the First Ray.” Foot Ankle Clin. 2000.

Nery, C, et al. “HalluxValgus in Males – Part I: Demographics, Etiology, and Comparative Radiology.” Am Ortho Foot and Ankle Society. 2013; 34(5), 629-635

Rodriguez, S, et al. “The Use of Computerized Tomography In Determining Stature and Sex from Metatarsal Bones.” Legal Medicine. 16 (2014); 252-257.

Saffo, G, et al. “First Metatarsocuneiform Joint Arthrodesis: A Five-Year Retrospective Analysis.” J Foot Surgery 1989; 28(5).

HELPFUL WEBSITES

http://www.aofas.org/PRC/conditions/Pages/Conditions/First-Metatarsal-Fractures.aspx

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2532263/

http://www.podiatrytoday.com/pertinent-pearls-treating-first-mpj-injuries-athletes

https://www.ncbi.nlm.nih.gov/m/pubmed/11232392/

http://www.podiatrytoday.com/emerging-insights-first-ray-hypermobility

http://www.podiatrytoday.com/hallux-valgus-hypermobility-cause-or-effect

http://www.podiatrym.com/cme/CME1_916.pdf

http://www.aofas.org/PRC/conditions/Pages/Conditions/First-Metatarsal-Fractures.aspxhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC2532263/http://www.podiatrytoday.com/pertinent-pearls-treating-first-mpj-injuries-athleteshttps://www.ncbi.nlm.nih.gov/m/pubmed/11232392/http://www.podiatrytoday.com/emerging-insights-first-ray-hypermobilityhttp://www.podiatrytoday.com/hallux-valgus-hypermobility-cause-or-effecthttp://www.podiatrym.com/cme/CME1_916.pdf

THANK YOU!