James D. Michelson

Background: Pain in the hallux metatarsophalangeal joint (MTPJ) is very common, yet the underlying etiology remains unknown. Previous clinical research and biomechanical research has implicated stenosing flexor hallucis longus (FHL) tendonitis as a possible cause. The hypothesis of this study was that treatment solely focusing on alleviating restricted FHL excursion would be beneficial in patients with hallux MTPJ pain. Methods: This is a retrospective study of those treated in the Foot & Ankle Division between January 2009, and December 2018, who were diagnosed with FHL tendonitis with associated pain in the hallux MTPJ. Demographics, comorbidities, examination findings, imaging results, pain scores, treatment instituted, and outcome was obtained from the electronic medical record. The primary outcome was the improvement in the pain score (visual analog scale [VAS]). The surgical patients were included if their procedure was solely related to the FHL (posteromedial ankle release ± os trigonum resection). The decision to have surgery was analyzed by univariate and multivariable statistics using demographics, comorbidities, and clinical findings as potential factors ( P < .05). Results: In 75% (59 of 79 feet), nonoperative treatment of FHL stenosis resulted in a decrease in pain scores that the patients felt was satisfactory. The operative group that had an FHL release showed decreased pain in 90% (18 of 20 feet). Multivariable analysis identified the need for immobilization (OR 9.8, 95% CI 1.8-55.2, P = .009), participating in athletics (OR 8.7, 95% CI 1.8-42.2, P = .007), and higher initial VAS (OR 1.7, 95% CI 1.3-2.3, P < .001) as being associated with the decision for surgery. Conclusion: Previous biomechanical studies have suggested that stenosing FHL synovitis can cause increased intraarticular loading in the hallux MTPJ. The current clinical study supports this hypothesis, demonstrating that treatment focused on relieving restricted FHL excursion can ameliorate pain in the hallux MTPJ in select cases.

Background: The ideal fixation method for the first metatarsophalangeal joint (first MTP) remains uncertain. This study compares nonunion and revision surgery rates of first MTP arthrodesis between nonlocking semitubular plates and precontoured locking plates. Methods: Demographics, fixation technique, and complications of all patients who underwent primary first MTP arthrodesis between 2013 and 2018 were determined from radiographs and clinical records. Cost data were from a 1-year subset of isolated first MTP fusion surgeries. The primary outcome measures of this study were the nonunion and complication rates, with associated costs of patients undergoing first metatarsophalangeal arthrodesis with either a noncontoured semitubular plate or a precontoured locking plate. Results: The study included 189 patients, with a mean follow-up of 18.7 months. The overall nonunion rate was 10.1%, with no difference between the locking and nonlocking plates. The prevalence of a painful implant was also similar. Surgeries using locking plates cost an average of $1,500 more than those using nonlocked plates. Conclusions: Because there was no difference in revision between locking and nonlocking plate fixation for primary first MTP arthrodesis, routine use of the more expensive locking plates may not be justified. Level of evidence: Level III (Retrospective cohort study).

Justifications for the widespread adoption and integration of an electronic health record (EHR) have long leaned on the purported benefits of the technology. However, the performance of the EHR has been underwhelming relative to the promises of immediate access to relevant patient information, clinical decision supports, computerized ordering, and transferable patient data. In this narrative review, we provide an overview of the historical problems and limitations of the EHR, detail the core principles that define agile processes that may overcome the barriers faced by the current EHR, and re-imagine what an integrated, seamless EHR that serves its users and patients might look like. Moving forward, the EHR should be redesigned using a middle-out framework and empowering dual-type champions to maintain the sustainable diffusion of future innovations.