Opening wedge medial cuneiform osteotomy is an important adjunctive procedure to correct the forefoot varus component of a flatfoot deformity. Advantages of this technique in comparison to first tarsometatarsal arthrodesis include predictable union, preservation of first ray mobility, and the ability to easily vary the amount of correction. Because of the variety of hindfoot procedures done in these patients, the degree of hindfoot correction contributed by the cuneiform osteotomy alone could not be determined. We have had excellent results without major complications using this technique.

Background: Ligamentous and capsular insufficiency of the second metatarsophalangeal joint has been surgically treated for over two decades, mainly with indirect surgical repairs, which stabilize adjacent soft tissue and shorten or decompress the osseous structures. While ligamentous insufficiency has been described and recognized, degeneration of the plantar plate and tears of the capsule have rarely been documented. The purpose of this study was to document and describe the presence and pattern of plantar plate tears in specimens with crossover second toe deformities, and based on this, to develop an anatomical grading system to assist in the assessment and treatment of this condition. Methods: Sixteen below-knee cadaveric specimens with a clinical diagnosis of a second crossover toe deformity were examined, and dissected by removing the metatarsal head. The pathologic findings of plantar plate and capsular pathology, as well as ligamentous disruption, were observed and recorded. Demographics of the specimens were recorded, and simulated weightbearing radiographs were obtained prior to dissection so that pertinent angular measurements could be obtained. Results: Demographics demonstrated a high percentage of female specimens, and a typically older population that has been reported for this condition. Radiographic findings documented a high percentage of hallux valgus and hallux rigidus deformities. The MTP-2 and MTP-3 angles were divergent consistent with a crossover toe deformity. We consistently found transverse tears in the plantar plate region immediately proximal to the capsular insertion on the base of the proximal phalanx. With increasing deformity, wider distal transverse tears extending from lateral to medial were found. Midsubstance tears, collateral ligament tears, and complete disruption of the plantar plate were found in more severe deformities. Conclusion: In this largest series of cadaveric dissections of crossover second toe deformities, we describe the types and extent of plantar plate tears associated with increasing deformity of the second ray. We present, based on these findings, an anatomic grading system to describe the progressive anatomic changes in the plantar plate.

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Level IV, prospective case series.

Level II, prospective cohort study.

The use of artificial turf in the United States has created a dramatic increase in first metatarsophalangeal joint dorsiflexion injuries. Turf toe has been reported to occur in athletes who participate in sporting activities. An injury to the plantar capsular ligamentous complex can result in acute and chronic pain, resulting in time lost from sports participation for a short- or long-term period. Classification of this injury is based on clinical findings and imaging studies, including plain radiographs and magnetic resonance imaging. The early recognition of this injury is crucial to successful treatment. Nonoperative treatment may often suffice for incomplete injuries; however, surgery may be warranted for a complete plantar plate disruption or injury to one or both sesamoids. In the high-performance or elite athlete, a turf toe or severe dorsiflexion injury can be disabling, and can threaten an athlete's career if not treated properly.

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The stereochemistry of base-catalyzed H/D exchange on 13 β-substituted ethyl butanoates in ethanol-d has been studied in order to analyze the steric and electronic factors which control the diastereoselectivity of electrophilic attack on enolate anions. Electrophilic deuteration of the enolate anion also determines the stereoselectivity of 1,4-conjugate addition of ethanol-d to α,β-unsaturated esters. Experimental conditions were selected which rigorously exclude the effects of ion pairing and aggregation. The research showed that stereoelectronic factors generally produce higher stereoselection than steric effects do. Electronegative heteroatom substituents at C-3 produced a 10:1 ratio of the 2R*,3R*/2R*,3S* 2-deuteriobutanoates. In the most stable transition states for electrophilic attack, these electronegative substituents occupy an antiperiplanar position to the forming C−D bond. Only with a β-tert-butyl substituent did steric effects produce high stereoselection, and it fell off rapidly with a decrease in carbon branching. Protonation of acyclic β-ethoxy aldehyde and ketone enolates follows the same diastereoselectivity pattern as the β-ethoxy ester enolate, but protonation of the cyanocarbanion from a β-ethoxy nitrile gives much lower stereoselection.