The Journal of Foot & Ankle Surgery 53 (2014) 328–330
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Lateral Collateral Ligament Reconstruction for Chronic Varus Instability of the Hallux Interphalangeal Joint Jaeho Cho, MD Department of Orthopedic Surgery, Seoul Paik Hospital, Inje University, Jeo-Dong, Jung-Gu, Seoul, Republic of Korea
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4
Chronic varus instability of the hallux interphalangeal joint is a rare injury, and only a few reports of this injury have been published. In some studies, this injury has been related to taekwondo. Taekwondo is an essential martial art in the Korean military. We have described a case of varus instability of the hallux interphalangeal joint in a professional soldier who had practiced taekwondo for 5 years and the surgical outcome after reconstruction of the lateral collateral ligament with the fourth toe extensor tendon. Ó 2014 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: extensor tendon great toe injury ligament soldier taekwondo
Forefoot injuries are common in runners and martial art athletes (1), and injury to the metatarsophalangeal joint of the great toe is relatively common compared with injury to the interphalangeal joint (IPJ) (2). The hallux IPJ is a simple hinge joint that allows motion in a sagittal plane; thus, this joint has been regarded as inherently stable and has received little attention in athletic injuries compared with the metatarsophalangeal joint (2). Shin et al (3) described injury to IPJ of the great toe that occurred during barefoot high-kicking or fast, running, turning exercises in a taekwondo gymnasium. We report a case of varus instability of the hallux IPJ in a professional soldier who had practiced taekwondo for 5 years and the surgical outcome after reconstruction of the lateral collateral ligament with the fourth toe extensor tendon.
Case Report A 25-year-old male soldier presented with pain and instability of the hallux IPJ in his right foot. The symptoms had developed after spraining the big toe several times when he had rapidly raised the foot for a kick and the great toe had been caught in the side of the mat during taekwondo. The hallux IPJ was apparently unstable and easily subluxable medially. Tenderness was present on the lateral side of the
Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Jaeho Cho, MD, Institute of Foot and Ankle Disease, Seoul Foot and Ankle Center, Department of Orthopedic Surgery, Seoul Paik Hospital, Inje University, No. 85 2-Ga, Jeo-Dong, Jung-Gu, Seoul, 100-032, Republic of Korea. E-mail address: [email protected]
joint but not on the dorsal or plantar side. Radiographic examinations showed no structural abnormality; however, a varus stress radiograph revealed a remarkable widening of the joint space laterally (Fig. 1). Buddy taping of the first and second toes was ineffective, and the patient required a stable joint to continue training. We thought repair of the ligament would be impossible or unreliable owing to the chronicity of the injury and, thus, planned to use a lateral collateral ligament. A lateral longitudinal incision over the hallux IPJ was made, and the IPJ was reached dorsal to the volar neurovascular structures. The proximal portion of the ligament had healed with scar tissue; however, the quality of the tissue was inadequate for direct repair or plication. One half of fourth toe extensor digitorum longus tendon was taken from the metatarsal bone level using 2 small transverse incisions. Each end of the harvested tendon was prepared with a whip stitch for easy handling during passage. Drill holes were made parallel to the joint at the normal insertion sites of the collateral ligament. After drilling a drill according to the graft size, the distal phalanx end of the prepared tendon was fixed using Mini Bio-SutureTakÒ (Arthrex, Naples, FL), similar to the method of fixation using the Bio-Tenodesis Interference Screw (Arthrex). Additionally, 2-0 FiberWire suture of the suture anchor (Arthrex) was placed at the point at which the graft was fixed. In the same manner as for the distal phalanx end, the proximal phalanx end of the tendon graft was secured after checking for a full range of motion of the joint (Fig. 2). After 4 weeks of immobilization, the IPJ was mobilized for active range of motion, and 3 months after the operation, the patient was allowed to participate in training in the Korean military. At 1 year postoperatively, the patient remained asymptomatic, and the IPJ was stable and congruent, without any varus instability and with 45 of flexion and full extension (Fig. 3).
1067-2516/$ - see front matter Ó 2014 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2013.12.016
J. Cho / The Journal of Foot & Ankle Surgery 53 (2014) 328–330
329
Fig. 1. (A and B) Varus stress radiograph showing marked widening of the lateral side of the right hallux interphalangeal joint.
Discussion The hallux IPJ is stable anatomically. The collateral ligaments, which attach to the lateral side of the proximal phalangeal head and
Fig. 3. (A and B) At 1 year postoperatively, the hallux interphalangeal joint remained congruent. A varus stress radiograph showed the disappearance of the lateral instability of the interphalangeal joint, resulting in a stable and painless hallux.
Fig. 2. Artistic drawing depicting our surgical method for reconstruction of the lateral collateral ligament of the interphalangeal joint with the fourth toe extensor tendon. Arrows indicate Mini Bio-SutureTakÒ (Arthrex, Naples, FL); crosses, 2-0 FiberWire suture (Arthrex).
the dorsal tubercle at the base of the distal phalanx, act as a strong static stabilizer in the transverse plane (2). The joint capsule and its thickened fibrocartilaginous plantar plate and the flexor and extensor hallucis longus tendons provide the sagittal plane stability. The bicondylar shape of the joint and the short lever arm of the distal phalanx also contribute to the stability (4). When force is directed on the joint in the transverse plane, traumatic dorsal dislocation can occur. Also, when force is directed on the joint in the transverse plane, intra-articular fractures have seemed to occur more commonly than ligament ruptures because of the strong collateral ligaments and the stable joint structure (5). Thus, lateral collateral ligament injury of the IPJ of the great toe or varus instability of the hallux IPJ has been uncommon. Shin et al (3) reported a case series of open lateral collateral ligament injury associated with or without medial subluxation of the IPJ of the great toe in adolescents performing taekwondo. Their proposed pathomechanism of the injury was that when the whole body is revolving about the distal phalanx, which is the only structure that supports the body weight, tremendous rotational forces can be generated at the IPJ. As a result, nonphysiologic varus stress will concentrate at the IPJ of the great toe. This results in open injury, with detachment or elongation of the lateral collateral ligament from the proximal phalanx. Medial subluxation or dislocation can occur in the presence of severe tensile stress on the IPJ. Our patient was a professional soldier who had usually exercised barefoot, performing high kicking or fast, running and turning exercises in a taekwondo gymnasium for 5 years. The mechanism of injury in our patient was similar to that reported by Shin et al (3). However, varus instability of the hallux IPJ, instead of an open lateral collateral ligament injury, occurred during the repetitive taekwondo training in our patient.
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J. Cho / The Journal of Foot & Ankle Surgery 53 (2014) 328–330
Also, the proximal portion of the ligaments had healed with scar tissue, although the quality of the tissue was inadequate for direct repair or plication. Compact Sharpey’s fiber bundles are located on the distal phalanx and are relatively loosely attached to the proximal phalanx (3). We assumed these structural characteristics contributed to the opening of the IPJ. We reconstructed the collateral ligament of the hallux IPJ with varus instability in a soldier and obtained a stable and mobile joint that enabled the patient to continue military training. Arthrodesis of the joint could be an option and would have provided more definite stability for daily activities. However, we assumed that a soldier who frequently runs, jumps, and kicks would require a mobile IPJ with adequate flexion movement during the push-off phase. Gong et al (6) reported reconstruction of the lateral collateral ligament using the palmaris longus tendon. However, we chose the fourth toe extensor tendon for the donor tendon in our patient. Biomechanically, the extensor digitorum longus tendon has shown greater cross-sectional area and stiffness than the palmaris longus or plantaris tendon and, thus, could be well suited for joint-stabilizing procedures (7). One study reported that sacrifice of the toe extensor did not lead to any functional impairment (8). We believed the advantages of using the extensor digitorum longus tendon as a graft included no need for an additional drape for harvesting and no functional impairment after harvesting. In conclusion, taekwondo is a popular martial art that originated in Korea and is an essential component in the Korean military. Many
Korean military soldiers participate in this sport. They usually perform fast, powerful, high kicks using the dorsum or lateral side of the bare foot. Thus, they have a greater risk of this type of great toe injury than of other sports-related hallux injuries. Preventive measures such as adequate footwear that can cover the IPJ on the bare foot should be developed. Finally, Korean military soldiers should be warned about this type of forefoot injury during taekwondo training.
References 1. Watson TS, Anderson RB, Davis WH. Periarticular injuries to the hallux metatarsophalangeal joint in athletes. Foot Ankle Clin 5:687–713, 2000. 2. Salleh R, Beischer A, Edwards WH. Disorders of the hallucal interphalangeal joint. Foot Ankle Clin 10:129–140, 2005. 3. Shin YW, Choi IH, Rhee NK. Open lateral collateral ligament injury of the interphalangeal joint of the great toe in adolescents during taekwondo. Am J Sports Med 36:158–161, 2008. 4. Noonan R Jr, Thurber NB. Irreducible dorsal dislocation of the hallucal interphalangeal joint. J Am Podiatr Med Assoc 77:98–101, 1987. 5. Kensinger DR, Guille JT, Horn BD, Herman MJ. The stubbed great toe: importance of early recognition and treatment of open fractures of the distal phalanx. J Pediatr Orthop 21:31–34, 2001. 6. Gong HS, Kim YH, Park MS. Varus instability of the hallux interphalangeal joint in a taekwondo athlete. Br J Sports Med 41:917–919, 2007. 7. Carlson GD, Botte MJ, Josephs MS, Newton PO, Davis JL, Woo SL. Morphologic and biomechanical comparison of tendons used as free grafts. J Hand Surg Am 18:76–82, 1993. 8. Takahashi T, Nakahira M, Kaho K, Kawakami T. Anatomical reconstruction of chronic lateral ligament injury of the ankle using pedicle tendon of the extensor digitorum longus. Arch Orthop Trauma Surg 123:175–179, 2003.
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Lateral Collateral Ligament Reconstruction for Chronic Varus Instability of the Hallux Interphalangeal Joint Jaeho Cho, MD Department of Orthopedic Surgery, Seoul Paik Hospital, Inje University, Jeo-Dong, Jung-Gu, Seoul, Republic of Korea
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4
Chronic varus instability of the hallux interphalangeal joint is a rare injury, and only a few reports of this injury have been published. In some studies, this injury has been related to taekwondo. Taekwondo is an essential martial art in the Korean military. We have described a case of varus instability of the hallux interphalangeal joint in a professional soldier who had practiced taekwondo for 5 years and the surgical outcome after reconstruction of the lateral collateral ligament with the fourth toe extensor tendon. Ó 2014 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: extensor tendon great toe injury ligament soldier taekwondo
Forefoot injuries are common in runners and martial art athletes (1), and injury to the metatarsophalangeal joint of the great toe is relatively common compared with injury to the interphalangeal joint (IPJ) (2). The hallux IPJ is a simple hinge joint that allows motion in a sagittal plane; thus, this joint has been regarded as inherently stable and has received little attention in athletic injuries compared with the metatarsophalangeal joint (2). Shin et al (3) described injury to IPJ of the great toe that occurred during barefoot high-kicking or fast, running, turning exercises in a taekwondo gymnasium. We report a case of varus instability of the hallux IPJ in a professional soldier who had practiced taekwondo for 5 years and the surgical outcome after reconstruction of the lateral collateral ligament with the fourth toe extensor tendon.
Case Report A 25-year-old male soldier presented with pain and instability of the hallux IPJ in his right foot. The symptoms had developed after spraining the big toe several times when he had rapidly raised the foot for a kick and the great toe had been caught in the side of the mat during taekwondo. The hallux IPJ was apparently unstable and easily subluxable medially. Tenderness was present on the lateral side of the
Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Jaeho Cho, MD, Institute of Foot and Ankle Disease, Seoul Foot and Ankle Center, Department of Orthopedic Surgery, Seoul Paik Hospital, Inje University, No. 85 2-Ga, Jeo-Dong, Jung-Gu, Seoul, 100-032, Republic of Korea. E-mail address: [email protected]
joint but not on the dorsal or plantar side. Radiographic examinations showed no structural abnormality; however, a varus stress radiograph revealed a remarkable widening of the joint space laterally (Fig. 1). Buddy taping of the first and second toes was ineffective, and the patient required a stable joint to continue training. We thought repair of the ligament would be impossible or unreliable owing to the chronicity of the injury and, thus, planned to use a lateral collateral ligament. A lateral longitudinal incision over the hallux IPJ was made, and the IPJ was reached dorsal to the volar neurovascular structures. The proximal portion of the ligament had healed with scar tissue; however, the quality of the tissue was inadequate for direct repair or plication. One half of fourth toe extensor digitorum longus tendon was taken from the metatarsal bone level using 2 small transverse incisions. Each end of the harvested tendon was prepared with a whip stitch for easy handling during passage. Drill holes were made parallel to the joint at the normal insertion sites of the collateral ligament. After drilling a drill according to the graft size, the distal phalanx end of the prepared tendon was fixed using Mini Bio-SutureTakÒ (Arthrex, Naples, FL), similar to the method of fixation using the Bio-Tenodesis Interference Screw (Arthrex). Additionally, 2-0 FiberWire suture of the suture anchor (Arthrex) was placed at the point at which the graft was fixed. In the same manner as for the distal phalanx end, the proximal phalanx end of the tendon graft was secured after checking for a full range of motion of the joint (Fig. 2). After 4 weeks of immobilization, the IPJ was mobilized for active range of motion, and 3 months after the operation, the patient was allowed to participate in training in the Korean military. At 1 year postoperatively, the patient remained asymptomatic, and the IPJ was stable and congruent, without any varus instability and with 45 of flexion and full extension (Fig. 3).
1067-2516/$ - see front matter Ó 2014 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2013.12.016
J. Cho / The Journal of Foot & Ankle Surgery 53 (2014) 328–330
329
Fig. 1. (A and B) Varus stress radiograph showing marked widening of the lateral side of the right hallux interphalangeal joint.
Discussion The hallux IPJ is stable anatomically. The collateral ligaments, which attach to the lateral side of the proximal phalangeal head and
Fig. 3. (A and B) At 1 year postoperatively, the hallux interphalangeal joint remained congruent. A varus stress radiograph showed the disappearance of the lateral instability of the interphalangeal joint, resulting in a stable and painless hallux.
Fig. 2. Artistic drawing depicting our surgical method for reconstruction of the lateral collateral ligament of the interphalangeal joint with the fourth toe extensor tendon. Arrows indicate Mini Bio-SutureTakÒ (Arthrex, Naples, FL); crosses, 2-0 FiberWire suture (Arthrex).
the dorsal tubercle at the base of the distal phalanx, act as a strong static stabilizer in the transverse plane (2). The joint capsule and its thickened fibrocartilaginous plantar plate and the flexor and extensor hallucis longus tendons provide the sagittal plane stability. The bicondylar shape of the joint and the short lever arm of the distal phalanx also contribute to the stability (4). When force is directed on the joint in the transverse plane, traumatic dorsal dislocation can occur. Also, when force is directed on the joint in the transverse plane, intra-articular fractures have seemed to occur more commonly than ligament ruptures because of the strong collateral ligaments and the stable joint structure (5). Thus, lateral collateral ligament injury of the IPJ of the great toe or varus instability of the hallux IPJ has been uncommon. Shin et al (3) reported a case series of open lateral collateral ligament injury associated with or without medial subluxation of the IPJ of the great toe in adolescents performing taekwondo. Their proposed pathomechanism of the injury was that when the whole body is revolving about the distal phalanx, which is the only structure that supports the body weight, tremendous rotational forces can be generated at the IPJ. As a result, nonphysiologic varus stress will concentrate at the IPJ of the great toe. This results in open injury, with detachment or elongation of the lateral collateral ligament from the proximal phalanx. Medial subluxation or dislocation can occur in the presence of severe tensile stress on the IPJ. Our patient was a professional soldier who had usually exercised barefoot, performing high kicking or fast, running and turning exercises in a taekwondo gymnasium for 5 years. The mechanism of injury in our patient was similar to that reported by Shin et al (3). However, varus instability of the hallux IPJ, instead of an open lateral collateral ligament injury, occurred during the repetitive taekwondo training in our patient.
330
J. Cho / The Journal of Foot & Ankle Surgery 53 (2014) 328–330
Also, the proximal portion of the ligaments had healed with scar tissue, although the quality of the tissue was inadequate for direct repair or plication. Compact Sharpey’s fiber bundles are located on the distal phalanx and are relatively loosely attached to the proximal phalanx (3). We assumed these structural characteristics contributed to the opening of the IPJ. We reconstructed the collateral ligament of the hallux IPJ with varus instability in a soldier and obtained a stable and mobile joint that enabled the patient to continue military training. Arthrodesis of the joint could be an option and would have provided more definite stability for daily activities. However, we assumed that a soldier who frequently runs, jumps, and kicks would require a mobile IPJ with adequate flexion movement during the push-off phase. Gong et al (6) reported reconstruction of the lateral collateral ligament using the palmaris longus tendon. However, we chose the fourth toe extensor tendon for the donor tendon in our patient. Biomechanically, the extensor digitorum longus tendon has shown greater cross-sectional area and stiffness than the palmaris longus or plantaris tendon and, thus, could be well suited for joint-stabilizing procedures (7). One study reported that sacrifice of the toe extensor did not lead to any functional impairment (8). We believed the advantages of using the extensor digitorum longus tendon as a graft included no need for an additional drape for harvesting and no functional impairment after harvesting. In conclusion, taekwondo is a popular martial art that originated in Korea and is an essential component in the Korean military. Many
Korean military soldiers participate in this sport. They usually perform fast, powerful, high kicks using the dorsum or lateral side of the bare foot. Thus, they have a greater risk of this type of great toe injury than of other sports-related hallux injuries. Preventive measures such as adequate footwear that can cover the IPJ on the bare foot should be developed. Finally, Korean military soldiers should be warned about this type of forefoot injury during taekwondo training.
References 1. Watson TS, Anderson RB, Davis WH. Periarticular injuries to the hallux metatarsophalangeal joint in athletes. Foot Ankle Clin 5:687–713, 2000. 2. Salleh R, Beischer A, Edwards WH. Disorders of the hallucal interphalangeal joint. Foot Ankle Clin 10:129–140, 2005. 3. Shin YW, Choi IH, Rhee NK. Open lateral collateral ligament injury of the interphalangeal joint of the great toe in adolescents during taekwondo. Am J Sports Med 36:158–161, 2008. 4. Noonan R Jr, Thurber NB. Irreducible dorsal dislocation of the hallucal interphalangeal joint. J Am Podiatr Med Assoc 77:98–101, 1987. 5. Kensinger DR, Guille JT, Horn BD, Herman MJ. The stubbed great toe: importance of early recognition and treatment of open fractures of the distal phalanx. J Pediatr Orthop 21:31–34, 2001. 6. Gong HS, Kim YH, Park MS. Varus instability of the hallux interphalangeal joint in a taekwondo athlete. Br J Sports Med 41:917–919, 2007. 7. Carlson GD, Botte MJ, Josephs MS, Newton PO, Davis JL, Woo SL. Morphologic and biomechanical comparison of tendons used as free grafts. J Hand Surg Am 18:76–82, 1993. 8. Takahashi T, Nakahira M, Kaho K, Kawakami T. Anatomical reconstruction of chronic lateral ligament injury of the ankle using pedicle tendon of the extensor digitorum longus. Arch Orthop Trauma Surg 123:175–179, 2003.
