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Report CopyRight/DMCA Form For : Diagnosis And Treatment Of First Metatarsophalangeal Joint
VOLUME 42 NUMBER 3 MAY JUNE 2003 125, FIGURE 1 Etiology of hallux rigidus MPJ metatarsophalangeal joint. lished arthrosis to ankylosis describing the end stage cation has been adopted 6 10 16 Therefore a patient. joint disease Later a fourth stage was included to may present with little to no radiographic joint findings. address the biomechanical imbalance without radio stage I or severe end stage arthrosis stage IV Figs. graphic joint changes 7 This modified 4 stage classifi 3 6. FIGURE 2 Normal first MTP joint motion A requires initial stability of the first metatarsal and subsequent plantarflexion In the presence. of B first ray instability ROM is restricted with jamming of the base of the proximal phalanx into the first metatarsal head and thus initiating. the degenerative process,126 THE JOURNAL OF FOOT ANKLE SURGERY. Initial Treatment Options Node 5 Metatarsal osteotomy Metatarsal osteotomy is per. formed to plantarflex the first metatarsal to transpose a. Initial treatment options are symptom driven 17 Joint distal segment in a plantar direction to realign the metatar. pain capsulitis or other acute episodic pain may be allevi sal articular surface or to shorten the metatarsal to achieve. ated with the use of nonsteroidal anti inflammatory drugs decompression 6 7 10 22 40 47 Both distal and proximal. 18 Judicious use of corticosteroid injections may provide osteotomies have been performed for correction of these. rapid relief even in recalcitrant joint pain Modalities that deformities Figure 13 shows the comparison of the surgical. relieve inflammation and pain are often indicated procedures. Biomechanical treatment is often an integral component The extent of elevatus will determine the anatomic loca. of initial treatment Orthotic management in the treatment tion of the osteotomy Distal first metatarsal procedures can. of hallux rigidus should attempt to improve the abnormal provide for plantar displacement of the capital fragment but. pathomechanics or to limit joint motion 12 19 20 Shoe to a lesser degree than a proximal osteotomy Often mod. modifications with stiff or rocker bottom soles or extra erate degrees of elevatus can be reduced simply through a. depth shoes may be helpful joint decompression procedure Fig 8. Early surgical intervention with performance of joint In cases of significant metatarsus primus elevatus a prox. preservation procedures may be appropriate in patients with imal osteotomy should be considered These procedures. lesser degrees of arthrosis Although it has not been proven should be reserved for rigid or structural deformity as. this may restore function and should be part of the patient opposed to positional elevatus A variety of osteotomies. education process have also been described to plantarflex the first metatarsal. such as the sagittal Z or crescentic osteotomy 30 Alter. natively the Lapidus first metatarsal cuneiform arthrodesis. Clinical Response Node 6, with or without a bone graft may be considered Fig 9. Phalangeal osteotomy Limitation of first MTP joint dor. When nonsurgical care is rendered the clinical response. siflexion in patients with hallux rigidus and the presence of. is assessed If the patient is doing well initial treatment may. an adequate range of plantarflexion may be addressed. be continued Node 8 If there has been little or no im. through phalangeal osteotomy A dorsal based wedge os. provement or if initial improvement deteriorates surgical. teotomy within proximal phalanx realigns the toe and re. treatment is appropriate If a primary care physician per. duces the hallux equinus 7 48 53, formed the initial evaluation and treatment referral to a. A separate category of phalangeal osteotomies ap, podiatric foot and ankle surgeon is indicated Node 7. proaches the problem from the concept of joint decompres. Surgery is considered in patients who continue with. sion 6 10 30 47 54 By achieving relaxation of the first. symptoms Node 7 or simply prefer surgical intervention. MTP joint any secondary elevation of the first metatarsal as. Node 7 The surgical treatment of hallux rigidus will be. a result of hallux equinus should reduce Fig 10 This. predicated on recognition of the condition of the joint as one. should occur whether the relaxation is accomplished on the. that is still salvageable through primary joint reconstruction. phalangeal side or on the metatarsal side of the joint. or one that would be more appropriately treated with a. Chondroplasty At surgery the first metatarsal articular. joint destructive procedure Fig 7, surface must be evaluated Degeneration of the cartilagi. nous surface is usually present predominantly centrally and. Surgical Treatment Joint Salvage Procedures dorsally Chondroplasty by abrasion with or without sub. chondral drilling has been advocated to initiate cartilage. Joint preservation procedures usually use cheilectomy by repair of both chondromalacia and areas of full thickness. itself or in combination with additional procedures These cartilage excoriation 30 55. procedures include cheilectomy metatarsal osteotomy and. phalangeal osteotomy Chondroplasty has also been per. formed as an adjunctive procedure in this group Joint Destructive Procedures. Cheilectomy Cheilectomy is the resection of hypertro. phic bony or osteochondral proliferation along the periphery As the arthrosis of hallux rigidus progresses the first. of the articulation which may be restricting joint motion MTP joint may be altered to such an extent that salvage. 9 21 37 There is some debate about the appropriate procedures are not appropriate Joint destructive procedures. amount of bone that should be resected All osteophytosis include resection arthroplasty implant arthroplasty and ar. should be resected from the metatarsal phalanx and sesa throdesis. moids some authors advocate aggressive partial joint re Resection arthroplasty Resection arthroplasty of the first. sections 38 39 MTP joint may include excision of either or both sides of. VOLUME 42 NUMBER 3 MAY JUNE 2003 127, Classification of Hallux Rigidus Staging of Joint Pathology Based on Degree of Arthrosis. Stage I Stage of Functional Limitus,Hallux equinus flexus. Plantar subluxation proximal phalanx,Metatarsus primus elevatus. Joint dorsiflexion may be normal with nonweightbearing but. ground reactive forces elevate the first metatarsal and yield limita. No degenerative joint changes noted radiographically. Hyperextension of the hallucal interphalangeal joint. Pronatory architecture,Stage II Stage of Joint Adaptation. Flattening of the first metatarsal head,Osteochondral defect lesion. Cartilage fibrillation and erosion,Pain on end ROM. Passive ROM may be limited,Small dorsal exostosis,Subchondral eburnation. Periarticular lipping of the proximal phalanx the first metatarsal. head and the individual sesamoids,128 THE JOURNAL OF FOOT ANKLE SURGERY. Stage III Stage of Established Arthrosis,Severe flattening of the first metatarsal head. Osteophytosis particularly dorsally,Asymmetric narrowing of the joint space. Degeneration of articular cartilage,Erosions excoriations. Subchondral cysts,Pain on full ROM,Associated inflammatory joint flares. Stage IV Stage of Ankylosis,Obliteration of joint space. Exuberant osteophytosis with loose bodies within the joint space or. Deformity and or malalignment,Total ankylosis may occur. Inflammatory joint flares possible, Local pain is most likely secondary to skin irritation or bursitis. caused by the underlying osteophytosis,VOLUME 42 NUMBER 3 MAY JUNE 2003 129. FIGURE 7 Surgical treatment of hallux rigidus IPJ interphalangeal joint MC metacarpal. the joint In the case of hallux rigidus with its severe throsis in older patients with limited functional demands be. proliferative activity and progressive loss of joint space cause of frequency of postoperative metatarsalgia. resection arthroplasty reestablishes joint space and allows Interpositional implant arthroplasty Interpositional im. movement plant arthroplasty may be performed with hemi or double. The most commonly practiced resection arthroplasty is stem implants Hemi silicone implants were used in the past. the removal of the base of the proximal phalanx 54 but because of complications they are no longer considered. Resection arthroplasty varies from excision of only the appropriate for patients with hallux rigidus 61 67 The. proximal phalangeal base with cheilectomy of the first second generation of hemi implants is metallic and requires. metatarsal head to resection on both sides of the joint less bone resection and less disruption of the intrinsic mus. 38 39 47 56 60 culature these may be considered in younger patients Fig. The choice of procedure must be tailored to the age and the 11 68 69. biomechanical demands of the particular patient Resection Interpositional arthroplasty with double stem silicone. arthroplasties are probably most appropriate for end stage ar hinged implants is still a useful procedure for the end stage. 130 THE JOURNAL OF FOOT ANKLE SURGERY, FIGURE 8 Distal first metatarsal osteotomy may be performed to allow joint decompression shortening plantar transposition of the capital. fragment or realignment of the metatarsal articular surface A preoperative anteroposterior AP and B lateral radiograph and C. postoperative AP and D lateral views,VOLUME 42 NUMBER 3 MAY JUNE 2003 131. FIGURE 9 Proximal osteotomy may be performed as a metatarsal osteotomy or as shown a Lapidus first. metatarsal cuneiform fusion Preoperative A AP and B lateral radiographs show degenerative changes in. the presence of metatarsus primus elevatus treated with cheilectomy and metatarsal cuneiform fusion. Postoperative C AP and D lateral radiographs,FIGURE 10 Phalangeal os. teotomy is useful particularly,as a Regnauld decompression. procedure A Preoperative,AP radiograph of hallux valgus. rigidus with B postoperative,Regnauld phalangeal type pro. cedure with Herbert bone,screw fixation,FIGURE 11 Implant arthro. plasty is still a useful proce,dure for A stage 3 and 4 hal. lux rigidus with a B metallic,hemi implant,VOLUME 42 NUMBER 3 MAY JUNE 2003 133. FIGURE 12 First MTP joint,fusion is advocated in patients. with significant arthrosis and,provides a durable recon. struction A Preoperative and,B postoperative AP views. arthrosis of hallux 36 70 71 Titanium grommets are rec Summary. ommended as an adjunct to minimize ectopic bone forma. tion although their main benefit may be in protection of the Hallux rigidus is a progressive osteoarthrosis of the first. implant from the adjacent bone 71 Patients should be MTP joint and although numerous etiologic factors exist. informed of the alternatives to implant arthroplasty and their the most common are attributable to biomechanical defects. potential complications Surgical procedures have been discussed in light of appro. Total joint replacement Total joint systems have been priateness to the degree of joint arthrosis based on classi. designed for the first MTP joint generally as 2 component fication. nonconstrained articulations in an effort to allow motion in The goal is to reduce pain and to improve the function of. more than 1 plane Materials used for opposing articular the foot This means that a rational approach to joint pres. surfaces are chosen for their low coefficient of friction and ervation is necessary to salvage joints whenever possible. for their minimum wear characteristics Numerous implant particularly in the younger patient. systems have been developed during the years and several. are still used clinically although long term clinical useful. ness has yet to be established 72 73 Judicious use and Acknowledgment. strict criteria are recommended to avoid complications and. problematic revisions On behalf of the Americam College of Foot and Ankle. Arthrodesis Arthrodesis has been a mainstay of surgical Surgeons the authors acknowledge and thank Maria Bidny. treatment both as an initial treatment of end stage disease DPM who kindly supplied the line art that appears in this. and as a revision of prior surgical intervention 5 74 86 CPG. Although arthrodesis eliminates movement at the first MTP. joint it provides stability of the medial column and efficient References. weight transfer through the medial portion of the foot 87. 90 1 Camasta CA Hallux limitus and hallux rigidus Clinical examination. The technique of obtaining the arthrodesis is less a con radiographic findings and natural history Clin Podiatr Med Surg. sideration than the actual position of the fusion Fig 12 13 423 48 1996. 2 American College of Foot and Surgeons Hallux rigidus in the healthy. The sagittal plane position is based on the normal declina. adult In Preferred Practice Guidelines ACFAS Park Ridge IL. tion of the first metatarsal and the shoe types and functional 1993. demands of the patient The transverse plane position is 3 Bingold A Collins D Hallux rigidus J Bone Joint Surg 32B 214 222. usually reflected to that of the lesser toes 1950,134 THE JOURNAL OF FOOT ANKLE SURGERY. 4 Nilsonne H Hallux rigidus and its treatment Acta Orthop Scand 29 Keogh P Nagaria J Stephens M Cheilectomy for hallux rigidus Ir. 1 295 303 1930 J Med Sci 161 681 683 1992, 5 Shereff MJ Baumhauer JF Hallux rigidus and osteoarthrosis of the 30 Kissel CG Mistretta RP Unroe BJ Cheilectomy chondroplasty and. first metatarsophalangeal joint J Bone Joint Surg 80A 898 908 1998 sagittal Z osteotomy a preliminary report on an alternative joint. 6 Vanore JV O Keefe RG Pikscher I Bidny MG Hallux rigidus and preservation approach to hallux limitus J Foot Ankle Surg 34 312. limitus In Medical and Surgical Therapeutics of the Foot and Ankle 318 1995. pp 423 465 edited by DE Marcinko Williams and Wilkins Balti 31 Mackay DC Blyth M Rymaszewski LA The role of cheilectomy in. more 1992 the treatment of hallux rigidus J Foot Ankle Surg 36 337 340 1997. 7 Drago JJ Oloff L Jacobs AM A comprehensive review of hallux 32 Mann RA Coughlin MJ DuVries HL Hallux rigidus a review of the. limitus J Foot Surg 23 213 220 1984 literature and a method of treatment Clin Orthop 142 57 63 1979. 8 Goodfellow J Aetiology of hallux rigidus Proc R Soc Med 59 821 33 Mann RA Clanton TO Hallux rigidus treatment by cheilectomy. 824 1966 J Bone Joint Surg 70A 400 406 1988, 9 Mann RA Coughlin MJ Hallux valgus etiology anatomy treatment 34 Mulier T Steenwerckx A Thienpont E Sioen W Hoore KD Peeraer. and surgical considerations Clin Orthop 157 31 41 1981 L Dereymaeker G Results after cheilectomy in athletes with hallux. 10 Vanore JV Corey SV Hallux limitus rigidus and metatarsophalan rigidus Foot Ankle Int 20 232 237 1999. geal joint arthrosis In Comprehensive Textbook of Hallux Abducto 35 Nawoczenski DA Nonoperative and operative intervention for hallux. Valgus Reconstruction pp 209 241 edited by DE Marcinko Mosby rigidus J Orthop Sports Phys Ther 29 727 735 1999. St Louis 1992 36 Pontell D Gudas CJ Retrospective analysis of surgical treatment of. 11 McMaster MJ The pathogenesis of hallux rigidus J Bone Joint Surg hallux rigidus limitus clinical and radiographic follow up of hinged. 60B 82 87 1978 silastic implant arthroplasty and cheilectomy J Foot Surg 27 503 510. 12 Dananberg HJ Gait style as an etiology to chronic postural pain Part 1988. I Functional hallux limitus J Am Podiatr Med Assoc 83 433 441 37 Trantalis JJ The role of cheilectomy in the treatment of hallux rigidus. 1993 letter J Foot Ankle Surg 37 171 1998, 13 Lapidus PW Dorsal bunion its mechanics and operative correction 38 Grady JF Axe TM The modified Valenti procedure for the treatment. of hallux limitus J Foot Ankle Surg 33 365 367 1994. J Bone Joint Surg 22 627 637 1940, 39 Saxena A The Valenti procedure for hallux limitus rigidus discus. 14 Rzonca E Levitz S Lue B Hallux equinus The stages of hallux. sion p 511 J Foot Ankle Surg 34 485 488 1995, limitus and hallux rigidus J Am Podiatry Assoc 74 390 393 1984. 40 Selner AJ Bogdan R Selner MD Bunch EK Mathews RL Riley J. 15 Regnauld B Hallux rigidus In The Foot pp 345 359 edited by B. Tricorrectional osteotomy for the correction of late stage hallux limi. Regnauld Springer Verlag Berlin 1986, tus rigidus J Am Podiatr Med Assoc 87 414 424 1997. 16 Schuberth JM Elleby DH Gerbert J Jolly GP Oloff JM Pascalides. 41 Youngswick FD Modifications of the Austin bunionectomy for treat. JT Vanore JV White DL Hallux valgus in the healthy adult In. ment of metatarsus primus elevatus associated with hallux limitus J. Preferred Practice Guidelines p 11 edited by American College of. Foot Surg 21 114 116 1982,Foot and Ankle Surgeons ACFAS Park Ridge IL 1992. 42 Viegas GV Reconstruction of hallux limitus deformity using a first. 17 Smith RW Katchis SD Ayson LC Outcomes in hallux rigidus pa. metatarsal sagittal Z osteotomy discussion pp 261 262 J Foot An. tients treated nonoperatively a long term follow up study Foot Ankle. kle Surg 37 204 211 1998,Int 21 906 913 2000, 43 Ronconi P Monachino P Baleanu PM Favilli G Distal oblique. 18 Steinberg MD Therapy of osteoarthritis of the great toe and hallux. osteotomy of the first metatarsal for the correction of hallux limitus. rigidus JAMA 217 215 1971 and rigidus deformity J Foot Ankle Surg 39 154 160 2000. 19 Kilmartin TE Wallace WA Hill TW Orthotic effect on metatarso 44 Lundeen RO Rose JM Sliding oblique osteotomy for the treatment of. phalangeal joint extension A preliminary study J Am Podiatr Med hallux abducto valgus associated with functional hallux limitus J Foot. Assoc 81 414 417 1991 Ankle Surg 39 161 167 2000, 20 Stuck RM Moore JW Patwardhan AG Sartori M Forces under the 45 Feldman KA The Green Watermann procedure geometric analysis. hallux rigidus foot with surgical and orthotic intervention J Am and preoperative radiographic template technique J Foot Surg 31 182. Podiatr Med Assoc 78 465 468 1988 185 1992, 21 Geldwert JJ Rock GD McGrath MP Mancuso JE Cheilectomy still 46 Cavolo DJ Cavallaro DC Arrington LE The Watermann osteotomy. a useful technique for grade I and grade II hallux limitus rigidus J for hallux limitus J Am Podiatry Assoc 69 52 57 1979. Foot Surg 31 154 159 1992 47 Chang TJ Stepwise approach to hallux limitus A surgical perspective. 22 DeLauro TM Positano RG Surgical management of hallux limitus Clin Podiatr Med Surg 13 449 459 1996. and rigidus in the young patient Clin Podiatr Med Surg 6 83 92 1989 48 Blyth MJ Mackay DC Kinninmonth AW Dorsal wedge osteotomy in. 23 Easley ME Davis WH Anderson RB Intermediate to long term the treatment of hallux rigidus J Foot Ankle Surg 37 8 10 1998. follow up of medial approach dorsal cheilectomy for hallux rigidus 49 Citron N Neil M Dorsal wedge osteotomy of the proximal phalanx for. Foot Ankle Int 20 147 152 1999 hallux rigidus Long term results J Bone Joint Surg 69B 835 837. 24 Feldman RS et al Cheilectomy and hallux rigidus J Foot Surg 1987. 22 170 174 1983 50 Purvis CG Brown JH Kaplan EG Mann I Combination Bonney. 25 Hamilton WG O Malley MJ Thompson FM Capsular interpositional Kessel and modified Akin procedure for hallux limitus associated with. arthroplasty for severe hallux rigidus Foot Ankle Intl 18 68 70 1997 hallux abductus J Am Podiatry Assoc 67 236 240 1977. 26 Hattrup SJ Johnson KA Subjective results of hallux rigidus following 51 Thomas PJ Smith RW Proximal phalanx osteotomy for the surgical. treatment with cheilectomy Clin Orthop 226 182 191 1988 treatment of hallux rigidus Foot Ankle Int 20 3 12 1999. 27 Heller WA Brage ME The effects of cheilectomy on dorsiflexion of 52 Hanft JR Feiertag MA Schabler JA Janecki CJ Kashuk KB Prelim. the first metatarsophalangeal joint Foot Ankle Int 18 803 808 1997 inary report modifications of the Regnauld osteochondral autogenous. 28 Iqbal MJ Chana GS Arthroscopic cheilectomy for hallux rigidus graft J Foot Surg 29 577 580 1990. Arthroscopy 14 307 310 1998 53 Hanft JR Kashuk KB Toney M Schabler J Modifications of the. VOLUME 42 NUMBER 3 MAY JUNE 2003 135, Regnauld osteochondral autogenous graft for correction of hallux implant Results in patients who have degenerative joint disease failure. limitus valgus a 2 year review J Foot Surg 31 116 119 1992 of previous operations or rheumatoid arthritis J Bone Joint Surg. 54 Kravitz SR LaPorta GA Lawton JH KLL progressive staging clas 74A 552 563 1992. sification of hallux limitus and hallux rigidus Lower Extremity 1 55 71 Sebold EJ Cracchiolo A Use of titanium grommets in silicone implant. 66 1994 arthroplasty of the hallux metatarsophalangeal joint Foot Ankle Int. 55 Ritsila VA Santavirta S Alhopuro S Poussa M Jaroma H Rubak JM 17 145 151 1996. Eskola A Hoikka V Snellman O Osterman K Periosteal and peri 72 Gerbert J Chang TJ Clinical experience with two component first. chondral grafting in reconstructive surgery Clin Orthop 302 259 265 metatarsal phalangeal joint implants Clin Podiatr Med Surg 12 403. 1994 413 1995, 56 Beguin JM Poilvache G Schernberg F Gerard Y The treatment of 73 Koenig R Koenig total great toe implant Preliminary report J Am. hallux rigidus Apropos of 33 cases Acta Orthop Belg 50 489 498 Podiatr Med Assoc 80 462 468 1990. 1984 74 Myerson MS Schon LC McGuigan FX Oznur A Result of arthro. 57 Breitenseher MJ Toma CD Gottsauner Wolf F Imhof H Hallux desis of the hallux metatarsophalangeal joint using bone graft for. rigidus operated on by Keller and Brandes method radiological pa restoration of length Foot Ankle Int 21 297 306 2000. rameters of success and prognosis Rofo Fortschr Geb Rontgenstr 75 Mann RA Disorders of the first metatarsophalangeal joint J Am Acad. Neuen Bildgeb Verfahr 164 483 438 1996 Orthop Surg 3 34 43 1995. 58 Kravitz SR The Valenti procedure for hallux limitus rigidus discus 76 Wulker N Arthrodesis of the metatarsophalangeal joint of the large. sion pp 180 181 J Foot Ankle Surg 35 178 1996 toe Orthopade 25 187 193 1996. 59 Kurtz DH Harrill JC Kaczander BI Solomon MG The Valenti 77 Smith RW Joanis TL Maxwell PD Great toe metatarsophalangeal joint. procedure for hallux limitus a long term follow up and analysis J arthrodesis a user friendly technique Foot Ankle 13 367 377 1992. Foot Ankle Surg 38 123 130 1999 78 Calderone DR Wertheimer SJ First metatarsophalangeal joint arthro. 60 Weil LS The Valenti procedure for hallux limitus rigidus discussion desis utilizing a mini Hoffman External Fixator J Foot Ankle Surg. pp 180 181 J Foot Ankle Surg 35 179 180 1996 32 517 525 1993. 61 Albin RL Weil LS Flexible implant arthroplasty of the great toe an 79 O Doherty DP Lowrie IG Magnussen PA Gregg PJ The management. evaluation J Am Podiatry Assoc 64 967 975 1974 of the painful first metatarsophalangeal joint in the older patient Arthro. 62 LaPorta GA Pilla P Richter KP Keller implant procedure a report of desis or Keller s arthroplasty J Bone Joint Surg 72B 839 842 1990. 536 procedures using a silastic intramedullary stemmed implant J Am 80 Hawkins BJ Haddad RJ Hallux rigidus Clin Sports Med 7 37 49. Podiatry Assoc 66 126 147 1976 1988, 63 Mahieu C Chaput A Bouillet R The treatment of hallux rigidus using 81 Johansson JE Barrington TW Cone arthrodesis of the first metatar. Swanson s silastic implant single and double stem Clinical radio sophalangeal joint Foot Ankle 4 244 248 1984. graphical and pobobarographic review with a 16 year maximum fol 82 Fitzgerald JA Wilkinson JM Arthrodesis of the metatarsophalangeal. low up Acta Orthop Belg 58 314 324 1992 joint of the great toe Clin Orthop 157 70 77 1981. 64 Laird L Silastic joint arthroplasty of the great toe a review of 228 83 Moberg E A simple operation for hallux rigidus Clin Orthop 142. implants using the double stemmed implant Clin Orthop 225 268 55 56 1979. 272 1990 84 Coughlin M Arthrodesis of the first metatarsophalangeal joint with. 65 Mondul M Jacobs PM Caneva RG Crowhurst JA Morehead DE mini fixation plate fixation Orthopedics 13 1037 1044 1990. Implant arthroplasty of the first metatarsophalangeal joint a 12 year 85 Marin GA Arthrodesis of the metatarsophalangeal joint of the big toe. retrospective study J Foot Surg 24 275 279 1985 for hallux valgus and hallux rigidus A new method Int Surg 50 175. 66 Vanore JV O Keefe RG Pikscher I Complications of silicone im 180 1968. plants in foot surgery Clin Podiatry 1 175 198 1984 86 McKeever D Arthrodesis of the first metatarsophalangeal joint for. 67 Shankar NS Silastic single stem implants in the treatment of hallux halux valgus hallux rigidus and metatarsus primus varus J Bone Joint. rigidus Foot Ankle Int 16 487 491 1995 Surg 34A 129 134 1952. 68 Leavitt KM Nirenberg MS Wood B Yong RM Titanium hemi great 87 Henry AP Waugh W Wood H The use of footprints in assessing the. toe implant a preliminary study of its efficacy J Foot Surg 30 289 results of operations for hallux valgus A comparison of Keller s. 293 1991 operation and arthrodesis J Bone Joint Surg 57B 478 481 1975. 69 Townley CO Taranow WS A metallic hemiarthroplasty resurfacing 88 Moynihan F Disorders of toes Practitioner 222 30 36 1979. prosthesis for the hallux metatarsophalangeal joint Foot Ankle Int 89 Moynihan FJ Arthrodesis of the metatarso phalangeal joint of the. 15 575 580 1994 great toe J Bone Joint Surg 49B 544 551 1967. 70 Cracchiolo A Weltmer JB Lian G Dalseth T Dorey F Arthroplasty 90 Stokes IA Hutton WC Stott JR Lowe LW Forces under the hallux. of the first metatarsophalangeal joint with a double stem silicone valgus foot before and after surgery Clin Orthop 142 64 72 1979.
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tantangan, dan usaha adalah salah satu aspek dalam motivasi berprestasi yang paling banyak diteliti. Motivasi Ekstrinsik didasarkan pada insentif eksternal,
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