Gamekeeper’s Toe: A Case Series and Review of Surgically Treated Traumatic Hallux Varus Due to Lateral Collateral Ligament Injury

Abstract

Background:

Injuries to the lateral collateral ligament (LCL) of the first metatarsophalangeal (MTP) joint that are treated surgically are rare. We present 3 cases of traumatic LCL injury of the first MTP joint that were treated surgically for a Stener-like lesion preventing healing. Additionally, we present a review of previously published cases.

Methods:

Diagnosis was confirmed with magnetic resonance imaging and intraoperative stress tests, which demonstrated instability and LCL disruption with interposition of the adductor hallucis aponeurosis. All cases were managed operatively with suture anchor repair at the LCL origin or insertion. Patients were followed for 2-4 years postoperatively with outcomes assessed using the Foot and Ankle Outcome Score (FAOS) and the American Orthopaedic Foot & Ankle Society (AOFAS) Hallux Score.

Results:

Three LCL repairs were performed in 2 patients, including 1 with bilateral injuries. At final follow-up, both patients had returned to high-level athletic activity. The mean FAOS was 97% and the mean AOFAS Hallux Score was 91.67%. Literature review identified 10 prior case reports with heterogeneous surgical techniques but consistently favorable outcomes.

Conclusion:

This series presents a pattern of traumatic LCL injuries with a Stener-like lesion of the great toe that were treated with surgical repair and, to our knowledge, represents the first review of reported cases, offering a synthesis of diagnostic features, operative technique, and outcomes.

Level of Evidence:

Level IV, case series.

Introduction

Traumatic injuries to the metatarsophalangeal (MTP) joint are a well-recognized cause of pain and dysfunction. Plantar plate and medial collateral ligament complex injuries are well described in the literature. In contrast, there is a scarcity of information available on injuries to the lateral collateral ligament (LCL) complex. Such injuries are akin to ulnar collateral ligament (UCL) injuries of the thumb, where Stener lesions (interposition of the adductor aponeurosis) require operative management. A Stener-like lesion of the great toe has been described previously. ¹ It is plausible that some LCL injuries of the great toe may behave similar to UCL injuries.

The body of literature addressing LCL injuries to the great toe is composed of single-patient case reports. These reports encompass a heterogeneous mix of patient populations and injuries, resulting in significant variability in diagnostic characterization and surgical approaches. In addition, there is no comprehensive review of the literature addressing traumatic LCL injuries of the great toe or reliable outcome data. As a result, there is a lack of consensus on treatment options, surgical indications, and optimal operative techniques. We present 3 cases of traumatic LCL injuries and review the existing literature to summarize diagnostic findings, as well as surgical indications, techniques, and outcomes for these rare injuries.

Methods

In this retrospective case series, we include 3 cases of traumatic LCL injury of the first MTP that were treated with ligament repair. Patients presented with pain and sensations of instability in the great toe. Physical examination findings included tenderness and swelling without visible varus deformity, as well as varus laxity of the MTP joint. Initial weightbearing radiographs showed no fractures or deformities. Magnetic resonance imaging (MRI) demonstrated LCL ligament disruption with adductor hallucis aponeurosis interposition blocking re-apposition of the LCL complex—similar to a Stener lesion in the thumb.

All 3 cases (Table 1) were initially managed with boot immobilization. The patient with bilateral injuries (cases 1 and 2) completed 6 weeks of physical therapy for her initial injury without symptom resolution and subsequently elected to undergo attempted surgical repair. Given the similarity of her contralateral presentation, she chose to proceed with surgery earlier in the course of the second injury. The patient in case 3 was offered physical therapy but deferred and elected to undergo surgery 3 months after injury because of symptoms of persistent instability.

Table 1.

Overview of First MTP Injuries Treated With LCL Repair.

Case	Age	Sex	Injury Pattern	Anchor Location	Time to Repair(wk)	Final Follow-up(y)	AOFAS Hallux Score (%)	FAOS (%)
1	16	F	Full-thickness distal LCL disruption with adductor interposition	Proximal phalanx	8	4	90	94 (SS: 82, P: 92, FD: 100, FSR: 95, QL: 94)
2 a	16	F	Full-thickness distal LCL disruption with adductor interposition	First Metatarsal	3	3	85	94 (SS: 82, P: 92, FD: 100, FSR: 95, QL: 94)
3	38	M	Full-thickness distal LCL disruption with adductor interposition	First metatarsal	12	2	100	100 (SS: 100, P: 100, FD: 100, FSR: 100, QL: 100)

Abbreviations: AOFAS, American Orthopaedic Foot & Ankle Society; FAOS, Foot and Ankle Outcome Score; FD, function and daily living subtotal; FSR, function, sports, and recreational activities subtotal; LCL, lateral collateral ligament; MTP, metatarsophalangeal; P, pain subtotal; QL, quality of life subtotal; SS, symptoms and stiffness subtotal.

a

Case 2 was a contralateral injury in the same patient as case 1, 6 months after initial surgery.

Surgical repair was performed in the supine position. Fluoroscopic imaging was used to assess stability with varus, valgus, and anterior drawer stress testing. Isolated varus instability was identified in all cases. Surgical approach was performed dorsally in the 1-2 interspace. Significant scarring and adhesions were identified in all cases. A single suture anchor (Smith & Nephew Raptormite 3.0 PK) with No. 0 suture was placed adjacent to the LCL origin or insertion under fluoroscopy depending on which side had more robust soft tissue for repair. In 1 case, this anchor was placed into the proximal phalanx, and in 2 cases, the anchor was placed into the first metatarsal. The LCL tissue was repaired and the remaining LCL tissue was oversewn. After repair, varus stability was confirmed.

Patients were made nonweightbearing in a controlled ankle motion (CAM) boot. At 2 weeks, weightbearing as tolerated in the CAM boot was initiated, and patients began physical therapy at 6 weeks. Follow-up evaluation was conducted 2-4 years after surgery, at which time the American Orthopaedic Foot & Ankle Society (AOFAS) Hallux Score and the Foot and Ankle Outcome Score (FAOS) were collected. We chose to use the AOFAS score because of the historical nature of the measure and the inclusion of range of motion measurements. The FAOS was selected because of the comprehensive nature of the measure and the reliability and validity of the measure.

Results

Three LCL repairs were performed on 2 patients (Table 1). One patient had a left-sided injury that was surgically repaired and then sustained a right-sided injury 6 months postoperatively. At final follow-up, both patients reported full return to all activities without limitations. The patient with bilateral injuries was able to return to collegiate division 1 gymnastics, whereas the other patient was able to return to high-level beach volleyball. The average FAOS in the 2 patients was 97%, broken down into the following subtotals: Symptoms + stiffness, 91%; function, daily living, 100%; function, sports, and recreational activities, 97.5%; and quality of life, 97%. The average AOFAS Hallux Score across the 3 cases was 91.67%.

In all cases, intraoperative fluoroscopic stress testing revealed laxity to varus stress with stability to valgus stress and anterior drawer testing, at 8, 3, and 12 weeks from injury in cases 1, 2, and 3, respectively (Figure 1). Preoperative MRI revealed rupture of the lateral collateral ligament complex from the proximal phalanx. In these 3 cases, there appeared to be a Stener-like lesion with dorsal and proximal retraction of the torn LCL with interposition of the adductor hallucis aponeurosis (Figure 2).

Figure 1.

Intraoperative fluoroscopy demonstrating persistent instability with varus stress of the great toe at the metatarsophalangeal: (A) at 3 weeks from injury in case 2, (B) 8 weeks from injury in case 1, and (C) 12 weeks from injury in case 3.

Figure 2.

Coronal (short axis, A, B, C) and axial (long axis, D) T2-weighted 3T magnetic resonance images with fat saturation demonstrating a tear of the first metatarsophalangeal joint lateral collateral ligament (LCL) with interposition of the adductor hallucis aponeurosis beneath the disrupted LCL with Stener-like lesion in (A) case 1, (B) case 2, and (C, D) case 3. White arrows point to adductor hallucis aponeurosis, and red arrows point to the retracted LCL.

Discussion and Literature Review

Although iatrogenic hallux varus has been well described in the literature, traumatic varus instability of the MTP joint has not been widely studied, and there is no consensus on the optimal diagnosis and treatment for this injury pattern. We identified 10 previous single-patient case reports of traumatic hallux varus over 44 years.^{1 -10} Injuries occurred during everyday activities, athletic events, falls, and higher-energy traumas. Similarly, our patients injured themselves during sporting events (beach volleyball and gymnastics). Medial deviated force of the great toe with or without axial loading was commonly reported as the injury mechanism. Given the small number of reported cases over several decades, traumatic hallux varus with symptomatic late instability appears to be rare, and its true incidence and natural history remain unknown. The patient from cases 1 and 2 in this article is unique, as there are no prior case reports of bilateral traumatic hallux varus.

Surgical techniques varied across the case reports. Ligament repairs were completed with sutures (5 suture anchors and 1 bone tunnel) and via suture button stabilization (2 cases). Reconstructions were performed with EHB autograft (2 cases). Ligament repairs were completed to the proximal phalanx (2 cases), first metatarsal (1 case), and unknown location (4 cases). The repairs completed in this study used suture anchors to repair the native lateral ligamentous complex, which were then oversewed. The decision for location of the anchor placement was made based on intraoperative assessment of distal and proximal tissue quality. Similar to the findings in this series, the limited outcome data we have from these case reports suggests that any of these procedures are appropriate. There was only 1 reported revision surgery that was required due to a secondary traumatic event resulting in rerupture years after the index procedure. ⁹

One article reported outcome scores, ⁷ whereas the others simply stated patients were doing well and had resumed normal activity. In this study, patients scored highly on the AOFAS Hallux Score and FAOS, suggesting a good outcome from this operation in the first several years after surgery. Although the literature is sparse regarding the management of LCL injuries of the first MTP joint, parallels may be drawn to the well-studied UCL injury of the thumb, in which surgical management is reserved for injuries with a low likelihood of nonoperative healing. Similarly, it is reasonable to consider that many LCL injuries of the first MTP can be managed conservatively, and that surgical management may be indicated in cases of complete LCL rupture or interposition of the adductor hallucis aponeurosis/tendon between the LCL stump and its insertion site (Stener-like lesion). These parallels must be further studied to develop clinical management criteria and optimize patient outcomes.

All patients in this study demonstrated a similar pattern on MRI studies (dorsal and proximal retraction of the LCL structures with interposition of the adductor hallucis aponeurosis). In cases 1 and 3, intraoperative fluoroscopic varus stress tests demonstrated instability at 8 and 12 weeks from injury, which is longer than would be expected for ligamentous healing. This failure of stabilization suggests that there is an inability of the tissue to heal appropriately on its own, which is confirmed by the Stener-like lesions seen on MRI.

As with every surgery, shared decision making with the patient is essential to avoid overtreatment and unnecessary exposure to operative risk, particularly given the limited evidence regarding outcomes with operative and nonoperative management of this injury. The senior authors have only completed 3 repairs of these injuries in more than 20 years of combined practice and believe that in many cases, nonoperative initial management is appropriate. Surgical intervention should be reserved for patients who demonstrate persistent instability, desire a potentially more reliable and quicker recovery, and wish to regain full function. However, in athletes, consideration for earlier surgical intervention could be given to cases that demonstrate a Stener-like lesion as these cases may not heal in a timely fashion.

Limitations of this extended case report include the small number of cases presented. Although our article cannot provide guidance on patient selection, surgical indications, or the optimal surgical management of traumatic hallux varus, it represents the only review on the topic and adds to the literature with 3 additional cases that show similar diagnostic patterns and objective outcome data that have not previously been reported.

Conclusion

The cases in this study all appeared to have interposition of the adductor hallucis aponeurosis/tendon, blocking the torn LCL structures from reducing into their more anatomic position—similar to a Gamekeeper’s thumb Stener lesion. Additional study is required to identify which patients would benefit from surgery vs nonoperative management and explore the optimal surgical approach to traumatic hallux varus. Our hope is that this article will draw attention to this uncommon injury and help providers more effectively diagnose and treat this injury pattern in a timely fashion in the future.

Supplemental Material

sj-pdf-1-fao-10.1177_24730114251405256 – Supplemental material for Gamekeeper’s Toe: A Case Series and Review of Surgically Treated Traumatic Hallux Varus Due to Lateral Collateral Ligament Injury

Supplemental material, sj-pdf-1-fao-10.1177_24730114251405256 for Gamekeeper’s Toe: A Case Series and Review of Surgically Treated Traumatic Hallux Varus Due to Lateral Collateral Ligament Injury by Phillip Schmitt, Lauren Piana, G. Max Gosey, Peter T. Evangelista, Raymond Hsu and Brad Blankenhorn in Foot & Ankle Orthopaedics