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A new classification system for hallux limitus that is based on objective radiographic changes around the first metatarsophalangeal joint is introduced. The new system is demonstrated in a 3-year, 110-patient retrospective study. From the information gathered, a surgical algorithm has been developed. Statistical analysis demonstrates an 87% satisfaction rate with the recommended surgical algorithm.

The authors present a new alternative to the problem of hallux limitus/rigidus deformity. The new Bioaction great toe implant (Orthopaedic Biosystems, LTD, Scottsdale, Arizona) appears to be superior to the popular hinged implant, since it is comprised of two separate components and therefore appears to be more resilient to implant breakage/failure. This manuscript will examine the etiologic factors contributing to this deformity, a brief retrospective review of traditional surgical treatment and a case presentation utilizing the Bioaction great toe implant.

Multiple variations in partition of the hallux sesamoids have been described; however, to our knowledge, a coalition of the hallux sesamoids has never been presented. A case of coalition of the hallux sesamoids is presented and the literature is reviewed with respect to the possible significance of this anomaly.

A four generation autosomal dominant pedigree of brachydactyly type C is presented with its radiological features. The hands and feet were similarly affected. All the subjects showing these changes had shortening of the big toes and, in addition, had cupped ears.

Three hundred and thirty feet in 265 patients with polydactyly of the foot were classified on the basis of ray involvement and the level of duplication. Anatomic differences in bony structures according to x-ray and operative findings, external appearance of involved digits, associated anomalies, and familial incidence were studied. In medial-ray polydactyly, bilateral occurrence was common, and a higher frequency of associated anomalies was detected. Each involved foot with even the same level of duplication usually had a different morphologic pattern. In central-ray polydactyly, all patients except one had duplications of the second toe, commonly with unilateral involvement. Both components were underdeveloped, with delay in appearance of ossification areas. In two patients, each member of duplication had syndactyly with the neighboring toe, resembling the pattern of polysyndactyly-cleft hand complex. Lateral-ray polydactyl was classified into two new major groups based on ossification pattern and bony alignment: (1) fifty-ray duplication, referring to the medially duplicated supernumerary fifth toe, and (2) sixth-ray duplication, referring to the laterally duplicated supernumerary sixth toe. Fifth-ray duplication was much more frequent than sixth-ray duplication in the Japanese population. Many differences were noted between the two groups of lateral polydactyly. Syndactyly between the fourth and fifth toes was associated only with fifty-ray duplication. Ulnar polydactyly was associated only with sixth-ray duplication. In lateral polydactyly, every patient with bilaterally involved feet had similar groups of polydactyly bilaterally. All the patients in the same family also had similar groups of anomalies. These facts suggest independent etiologic mechanisms for each.

The authors present a case of Pfeiffer syndrome, which differs from the classic description. Treatment consisted of surgical correction of the unusual digital deformity. The literature is reviewed in regard to acrocephalosyndactyly and related congenital disorders and deformities.

Using data from the Spanish Collaborative Study of Congenital Malformations (ECEMC), we tested the hypothesis of Carey et al. (Proc Greenwood Genet Cent 9:95, (1990) on maternal diabetes and preaxial polydactyly of feet in infants born to diabetic mothers. Our results seem to confirm their suggestion, although the hallucal type of preaxial polydactyly that they described seems to be much less frequent. Nevertheless, a high risk exists (OR = 24.60, P = 0.0004) for preaxial polydactyly of the feet in relation with other types of birth defects or postaxial polydactyly. This analysis shows the importance of clinical observations for epidemiologists, because such observations constitute hypotheses and provide actual issues for study, and clinicians will get epidemiological confirmation for their individual observations and hypotheses.

Collapsing pes plano valgus deformity and pes cavus deformity have been identified and treated for many years. Recently, a combination of these deformities has been recognized occurring simultaneously. This multiplanar deformity is known as the cavo-valgus foot. Treatment of this foot type requires a firm understanding of planal dominance. The authors present a case report on this subject.

The authors describe a modification of the Akin procedure using a distal oblique osteotomy with rigid internal fixation. The anatomic, biomechanic, and physiologic advantages of this modification are discussed. Its proper use and an analysis of results is included.

Congenital hallux varus is uncommon as an isolated deformity. Many authors cite this deformity in conjunction with metatarsus varus or talipes equino varus deformities. An unusual case of bilateral congenital hallux varus is presented in a 9-month-old. A review of etiologies and treatment methods are given.

Proteus syndrome is a rare congenital disorder in which the major clinical manifestations are skeletal deformities and hamartomatous tumors. The case of a 42-year-old woman with right hemihypertrophy, macrodactyly of the right hallux, extreme kyphoscoliosis and bilateral plantar connective tissue naevi is reported. Proteus syndrome is reviewed with reference to this patient.

An excellent means of salvaging a deformity of the hallux, metatarsophalangeal joint arthrodesis should be technically simple and yield predictable results. The author reviews the literature on this procedure and presents the particular technique he has developed.

It is suggested that there is a group of cases of congenital angulation of tubular bones in which the lesion is a defect of ossification of the primary cartilaginous anlage and in which neurofibromatosis is not implicated. It appears that in this group the prognosis with regard to the resolution of deformity and the prevention of pseudarthrosis with conservative treatment or relatively simple surgical procedures is better than that in the neurofibromatous type.

The authors report on experience gained in the surgical treatment of eight patients with congenital hallux varus associated with polydactyly of the big toe. Aside from a description of the "radiological anatomy", the paper focuses in particular on the intraoperative soft tissue findings. In addition to the supernumerary bone structures, muscle and tendon anomalies were found in all the patients. In four patients the cause of the varus malposition was found to be fibrous stands extending from the rudimentary big toe to the tarsus. In five patients the abductor hallucis muscle was found to be shortened. An analysis of the surgical results shows that these soft tissue changes must be taken into account during surgery. In addition to complete removal of the polydactylic supernumerary, fibrous strands must be resected and shortened muscles severed or elongated. In many cases, operations on the basal joint capsule and plastic surgery are also necessary.

Acquired hallux varus may follow correction of hallux abducto valgus by the modified McBride procedure. The authors discuss correction of both acquired and congenital hallux varus and show pre- and postoperative illustrations of both types.

Two unrelated patients, a 4-year-old boy and a 2 1/2-year-old girl, presented with a similar pattern of abnormalities. Both had severe mental retardation, macrocephaly, absence of the corpus callosum, unusual facial appearance, duplication of hallucal phalanges, postaxial hexadactyly of finger phalanges, and 2/3-syndactyly of toes. The boy also had postaxial hexadactyly of toe phalanges, inguinal hernias and umbilical hernia, and growth retardation. We suspect a common cause of this apparently "new" syndrome, most likely a gene mutation.

The condition known as delta phalanx (or longitudinally bracketed epiphysis) is a rare congenital anomaly first described in 1964. The deformity consists of a triangular bone with an epiphysis running along the shortened side of the phalanx in a proximal to distal direction, making longitudinal growth of the digit impossible. Isolated hallux varus congenitus due to a delta phalanx of the proximal phalanges of both great toes is extremely rare: there have been only three such cases reported, two of which were in one family--the only report of a familial occurrence of this deformity. This present report details the occurrence of isolated bilateral hallux varus congenitus in four members of one family, a father and his three eldest children. All three children show bilateral delta phalanx of the proximal phalanges of both great toes. There are associated thumb nail anomalies, but no suggestion of polydactylism.

Congenital duplication of the foot and toes is a commonly diagnosed condition in newborn nurseries across the United States. The foot involvement varies from simple fleshy tags to complex attempts at whole extremity duplication. We reviewed 59 patients (82 feet) with a variety of duplications (excluding skin tags). During our review, we devised a new descriptive system of classification of congenital duplications of the foot based primarily on the type and complexity of the skeletal duplication. Variables related to sex, bilaterality, age at surgery, family history, and follow-up results were documented, and an exact classification of each foot was accomplished. Results and prognosis vary with the class of duplication being treated and must be individualized case by case.

We reviewed 12 patients with congenital hallux varus who had had operations on 20 feet to enable them to wear normal shoes and to improve the appearance. After an average follow-up of 12.7 years the results of soft tissue procedures were satisfactory in 12 of 17 feet. Arthrodesis of the first metatarsophalangeal joint, performed primarily in one foot and secondarily in two others was also satisfactory, but metatarsal osteotomy in two feet gave unsatisfactory results leading to local amputation. The unsatisfactory results were generally due to the appearance of shortness of the first metatarsal and rarely because of symptoms or recurrent deformity.

We report here a case of fibrodysplasia ossificans progressiva in a 14-year-old boy, affected from birth by microdactyly of the big toes. This skeletal abnormality also existed in his paternal great-grandfather. When he was 7, some ectopic ossifications occurred and inexorably progressed despite all therapies. Fibrodysplasia ossificans progressiva is a serious and rare disease with a terrible development, leading to a sort of petrifaction of the patient. The lack of knowledge on this ectopic ossification process explains the want of suitable treatments to stop the course of this disease.

Complex syndactyly of the hands and feet is a major deformity seen in children with Apert's syndrome. Also observed in the three patients presented in this paper was severe hallux valgus, which caused significant shoeing difficulties in two patients, for whom surgical correction was necessary. The two operative plans were based on the different underlying osseous abnormalities: (1) removal of the great toe with transposition of the second toe; (2) resection of the second ray with realignment of the great toe. Both procedures were successful from a functional and aesthetic viewpoint. When confronted with a child with Apert's syndrome who is having shoeing difficulty, assessment of the underlying osseous pathology is a mandatory step in the preoperative planning of surgical intervention.

This type of deformity does not appear often in any podiatric practice. An adequate regimen should be used to reduce deformity and, hopefully, to improve, or at least maintain, adequate function.

Preaxial polydactyly in 15 males and 5 females of 6 generations display a bilateral duplication of the big toe in a pedigree from Andhra Pradesh, India, with reduced penetrance and variable expressivity.

When cancellous bone for grafting cannot be obtained from conventional sources such as bone banks, the iliac crest, or the tibia, the author uses two alternative sources for obtaining wafer thin portions of bone: 1) the hypertrophied medial head of the first metatarsal and 2) the lateral base of the fifth metatarsal.

Two brothers with hallux varus of both feet are reported. One brother also had duplication/triplication of the great toes. The parents had no skeletal abnormalities or abnormalities of dermatoglyphics.

The Authors describe a bilateral congenital case of flexion and valgism of the IF of the hallux, since they are not mentioned in literature. On the basis of the operative examination it is thought that the etiopathogenesis may consist of a congenital retraction of the capsule, in plantar aspect, and of the collateral ligaments; they advise that surgical treatment should be carried out before the start of ambulation. The correction obtained proved stable over time.

28 cases of Taybi-Rubinstein syndrome with different radiological appearances are presented along with radiological differential diagnosis. Broadening of the distal phalanx of the thumb (68%) and great toe (64%) was the most common radiological sign followed by incomplete fissures of the distal phalanges of the thumb and first toes. Radiological examination in association with clinical signs and laboratory investigations is an essential part in the diagnosis of the Taybi-Rubinstein syndrome.

Although often neglected in the consideration of dancing and sports injuries, the great toe is as important as the other large joints of the lower limb. Many injuries to the great toe are associated with technical faults occurring during dancing, and these should be corrected or the injury will recur. It is also important that when a dancer presents with an injury elsewhere, the possibility of faults at the great toe be considered.

Although both congenital and acquired hallux varus have been described, the deformity has been considered uncommon. Contrary to this belief, we noted that it is fairly common in the unshod population. Analysis of 30 cases shows that congenital hallux varus is the most common type encountered and it is of three types, namely: primary, secondary, and teratogenic. The congenital primary and secondary varieties are apparently easy to treat in infancy, but if left untreated, they progress with age in unshod persons. The more severe grades of hallux varus are associated with medial deviation of the lateral toes. Hallux varus occasionally develops in unshod persons during the fourth, fifth, or sixth decades of life. This is referred to as the idiopathic hallux varus of middle age. The length of the first metatarsal, the first intermetatarsal angle, and the shape of the first metatarsal head appear to have no bearing on the causation of hallux varus. The progression of the deformity in congenital cases and the de novo development of the deformity in middle age appear to be related to the failure to use footwear.

A male patient presented with a pattern of congenital malformations including macrocephaly, absence of the corpus callosum, hypertelorism, small nose, bilateral inguinal hernias, postaxial polydactyly of all limbs and duplication with syndactyly of the big toes. His development was marked by growth retardation, repeated infections, cyanotic spells, seizures, and gross motor and mental retardation. This case probably represents a newly recognized malformation syndrome of hitherto unknown etiology.

Hallux varus was observed in 69 feet among patients from a rural Indian population. This included three types of congenital hallux varus. The congenital "primary" type was the commonest and was not associated with any other foot deformity. Among the acquired forms was idiopathic hallux varus of middle age, which developed spontaneously in unshod persons and progressed gradually. Hallux varus following chronic arthritis was part of a consistent pattern of foot deformities in which the first ray collapsed in a zig-zag manner in two planes. Although the development of hallux varus is often due to intrinsic muscle imbalance, hallux varus secondary to chronic arthritis seems to occur as a result of both intrinsic and extrinsic muscle imbalance associated with midtarsal and subtalar arthritis. Muscular factors contribute to progression of the deformity also. No anatomical basis for a racial predilection for the deformity was noted. Failure to use footwear could account for the higher incidence of hallux varus in India.

A new syndrome is described. Its distinguishing features are hallux syndactyly, ulnar polydactyly and abnormal earlobes with other roentgenographic abnormalities along the medial border of the foot. It is inherited as an autosomal dominant.

Sixteen patients with duplication of the hallux were reviewed. Follow-up averaged 21 years. Duplication may be classified into three groups: simple hallucal duplication, a transitional type with a short thick first metatarsal, and complete first ray duplication. Routine removal of the most medial hallux or ray is to be avoided. Careful preoperative assessment is necessary to compare hallucal function, cosmesis, and metatarsal weightbearing. Surgery should also correct the associated congenital hallux varus. Surgical complications include functionless hallucis from inappropriate selection and medial soft tissue contractures with either recurrence of the hallux varus or the gradual development of a hallux varus interphalangeus.

One hundred twenty-five patients with 194 supernumerary toes were analyzed. Postaxial polydactyly accounted for 79%. Duplication at the proximal phalanx with either a block metatarsal or a wide metatarsal head was the most common anatomical pattern. Sixty-one patients with 97 duplications evaluated at an average follow-up of 15.1 years postoperatively had 94% excellent or good results. Poor results were often associated with preaxial duplications and persistent hallux varus. Patients with central duplications often had a persistently wide forefoot. Surgical treatment is usually straightforward, but must be individualized. Preoperative radiologic assessment is mandatory. Certain technical considerations are related to better results.