[Long-term results of basal wedge osteotomy in metatarsus primus varus in the young patient]

INTRODUCTION

Aim of this retrospective study was to analyse the long term results after basal closing wedge osteotomy for correction of metatarsus primus varus and hallux valgus in the younger patient.

PATIENT AND METHODS

49 patients (70 feet) were operated according to a basal closing wedge osteotomy from 1974 to 1985 at our institution. Age was under 40 years in all patients at the time of surgery. 34 patients (50 feet) were evaluated in respect to their clinical and 26 patients (37 feet) to their radiological outcome. The average age was 26 years (14-39 years). The follow-up was 12 to 22 years (Median: 18 years). Analysis was performed using the patient's record, weight-bearing X-rays, a standardized questionnaire and clinical investigation.

RESULTS

82% of the patients had very good and good subjective results. Cosmetics was rated very good and good in 78%, 88% of the patients were painfree. Radiological analysis at follow-up: Hallux valgus-angle 19,3 degrees, intermetatarsal I/II-angle 6 degrees, shortening of first metatarsale 5 mm, at average; dorsal elevation of first metatarsale 38%, degenerative arthritis of the metatarsocuneiforme joint 19%, congruency of first metatarsophalangeal joint 54%,sesamoid subluxation: 46% grade 0, 30% grade I, 14% grade II and 10% grade III. In 14 feet (28%) metatarsalgia was found.

DISCUSSION

The basal closing wedge osteotomy is rather a technically demanding procedure conjuncted with a higher risk of failure. Satisfactory long term results can be obtained by an ideal operating technique. As undesirable side effects shortening of the first ray and dorsal malangulation of the first metatarsale may occur consecutively leading to metatarsalgia. Lower risk procedures like the crescentic osteotomy according to Mann or chevron osteotomy should be preferred.

Scintigraphic and clinical findings in the Standardbred metatarsophalangeal joint: 114 cases (1993-1995)

To correlate scintigraphic and clinical findings of the metatarsophalangeal joint (MTPJ) in Standardbreds, radiographic findings in horses with confirmed MTPJ lameness, and determine if stress reaction and more advanced bone remodelling occurred in the MTPJ, medical records of 114 Standardbreds admitted between September 1993 and April 1995 in which bone scintigraphy included standing lateral and plantar views of the metatarsophalangeal joint (MTPJ) were reviewed. Images obtained using a large field of view gamma camera were evaluated visually for location, definition and intensity of increased radioisotope uptake (IRU), which was graded as mild, moderate, or intense. Clinical history and lameness examination findings were recorded and, in horses with documented MTPJ lameness, radiographic examination included the 30 degree (down-angled) dorsolateral 45 degree plantaromedial view thought to be useful in evaluation of the plantarolateral condyle of the third metatarsal bone (MtIII). The most common abnormality, IRU of the plantarolateral aspect of MtIII, was seen in 67 horses, and horses were further classified according to scintigraphic and clinical findings. In 43 horses in which lameness was not localised to the MTPJ, mild (32 horses), moderate (10 horses), and intense (one horse) IRU of MtHII was found. In 24 horses with lameness localised to the MTPJ, moderate (18 horses) and intense (6 horses) IRU was found. Of 18 horses with moderate IRU of MtIII, 9 had radiographic evidence of abnormal bony remodelling of MtIII, whereas 5 of 6 horses with intense IRU had radiographic changes. In 12 horses with MTPJ lameness and radiographic evidence of bony remodelling without fracture, radiographic changes consisted of plantarolateral subchondral radiolucency and sclerosis (7 horses), radiolucency and osteochondrosis (one horse), and plantar MtIII sclerosis without radiolucency (4 horses). In 2 horses with moderate IRU and MTPJ lameness, radiographic evidence of radiolucency and MtIII fracture was found. Of 19 starters with MTPJ lameness and IRU of MtIII, 18 horses raced after diagnosis, but only 13 remained at the same racing class or improved. The results of this study suggest the most common scintigraphic abnormality of the MTPJ, IRU of the plantarolateral aspect of MtIII, may precede other stress-related changes, and in some horses is associated with a continuum of stress-related subchondral bone remodelling which results in lameness and later radiographic changes. Since 24 of 35 horses with moderate or intense IRU of MtIII had MTPJ lameness, and 5 of 7 horses with intense IRU of MtIII had lameness and radiographic evidence of abnormal remodelling, it was concluded that horses with advanced, scintigraphic findings are more likely to have lameness and radiographic evidence of subchondral bone damage.

A rare case of complete proximal epiphyses (so-called pseudoepiphyses) of the metacarpal and metatarsal bones in the human

We report a rare case of complete proximal epiphyses (so-called pseudoepiphyses) of metacarpal and metatarsal bones in a human. These phenomena were seen in both the hands and feet of a seven-year-old girl undergoing medical examination for pain in the right foot. During medical treatment, X-ray photographs of the hands and feet were taken. Each metacarpal and metatarsal bone except for the first metacarpal bones had supernumerary epiphyses (complete pseudoepiphyses) at the nonepiphyseal end of these bones. This is a rare case even for an experienced orthopaedic surgeon.

Arthrosonography--the use of diagnostic ultrasound in septic and traumatic arthritis in cattle--a retrospective study of 25 patients

The case records, clinical, radiographic, ultrasonographic and arthrocentesis findings from 25 cattle with septic or traumatic arthritis were reviewed. The total of 30 joints involved were: articulatio cubiti (elbow joint)-1, articulatio carpi (carpal joint)-10; articulatio genus (stifle joint)-4, articulatio tarsocruralis (tarsocrural joint)-8; articulatio metacarpo-/metatarsophalangea (metacarpo-/metatarsophalangeal joint -7. Ultrasonographic investigation was performed using 7.5 MHz linear and 5 MHz sector transducers. In eight cattle, a concurrent infection of periarticular tendon sheaths or hygroma was diagnosed. The distension of the joint cavities could be imaged in all cases. Assessing echogenicity, acoustic enhancement, ultrasonographic character of the exudate (liquid or clotted) and findings revealed by aspiration, arthrotomy or at necropsy, the synovial effusion was classified as: serous, fibrinous or fibrino-purulent. Diagnostic ultrasound provided a comprehensive preoperative diagnosis in septic and traumatic arthritis by imaging the accurate localization of soft-tissue swelling and the extent and consistency of joint effusion.

Mixed sclerosing bone dystrophy. Report of a case and review of the literature

A 63-year old woman was admitted because of hip pain. Radiographs showed multiple round and oval sclerotic lesions involving humeral heads, pelvis, vertebral bodies and both femoral bones. Diaphyseal periosteal proliferation was found in metatarsal bones. A diagnosis of mixed sclerosing bone dystrophy was made. We review clinical, epidemiological and radiological findings of this entity.

Spontaneous fusion of the midfoot following reflex sympathetic dystrophy. A case report and review of the literature

Reflex sympathetic dystrophy syndrome (RSDS) is a well-defined entity, caused by many clinical conditions, leading to pain, stiffness, and vasomotor changes in the affected region. In this case, a 49-year-old man presented with a history of right foot pain secondary to a fall. Plain radiographs did not reveal any fractures or bony fusions. Upon follow-up, a history consistent with that found in RSDS was given. Radiographs at 7 and 11 weeks revealed increasing osteopenia, lytic lesions, and absent joint spaces in the first through third metatarsocuneiform articulations suggesting ankylosis. Other possible causes of ankylosis, including infection, inflammatory and metabolic conditions, were excluded.

Hypertrophic osteopathy (Marie's disease) in Equidae: a review of twenty-four cases

The case records of 23 horses and one donkey affected by hypertrophic osteopathy (HO) (Marie's disease) were reviewed. All affected animals presented with limb swellings, which were bilaterally symmetrical and usually involved both fore- and hindlimbs. Associated signs included stiffness/lameness and weight loss. Radiological features included periosteal new bone formation over the diaphyses and metaphyses of affected bones. The metacarpal and metatarsal bones were most frequently affected. Articular surfaces remained free of disease. Seventeen animals were destroyed on humane grounds, 3 horses recovered after successful treatment of the primary disease, 3 horses recovered after symptomatic treatment and one horse was lost to follow-up. Significant primary diseases that were believed to predispose to HO were identified (pre- or post mortem) in 14 cases. In each of these cases, an intrathoracic disease was identified, although co-existing extrathoracic disease was present in 3 cases. Granulomatous inflammatory lesions were present in 9 of these 14 cases. In 4 horses, which underwent necropsy examination, no significant underlying disease was identified.

Metacarpal and metatarsal fractures in cattle

Metacarpal and metatarsal fractures are usually amenable to external coaptation using a short or full limb polyurethane resinimpregnated knitted fiberglass fabric cast. The prognosis for long-term pain-free survival is excellent for closed fractures and fair to good for open fractures managed in the manner. Surviving animals generally are not lame and do not demonstrate significant limb deformity or limb shortening and generally become completely productive. Even considering the narrow profit margin involved when treating cattle with serious injuries, this method of fracture management is usually economically and technically feasible.

Ultrasonographic anatomy of the dorsal and abaxial aspects of the equine fetlock

This paper describes normal ultrasound images of the soft tissues of the dorsal and abaxial aspects of the equine fetlock. The palmar aspect of the fetlock is not discussed because it is related to the suspensory apparatus and flexor tendon anatomy which has been previously described. Ultrasound scanning was performed with 7.5 MHz linear or 10 MHz sector probes and recorded on 7.5 cm U-matic videocassettes allowing further retrospective data analysis, computer manipulation and good image reproducibility. Sagittal, parasagittal, frontal and transverse ultrasound scans of 13 lameness free mature horses were compared to anatomically dissected leg specimens, anatomical sections and Magnetic Resonance Imaging scans of isolated limbs. The results are focused on the comparison between anatomical sections and ultrasonograms performed on the legs of nonlame horses. Ultrasonography was demonstrated to be a very accurate imaging procedure for soft tissue structures at the dorsal and abaxial aspects of the equine fetlock. Under clinical conditions, a thorough knowledge of normal ultrasonographic anatomy is critical for an accurate diagnosis of fetlock soft tissue injury.

Tendonitis of the deep digital flexor tendon in the distal metacarpal/metatarsal region associated with tenosynovitis of the digital sheath in the horse

Twenty-four horses with ultrasonographic evidence of tendonitis of the deep digital flexor tendon in the metacarpal/metatarsal region were seen over a 7 year period. Most horses had mild to moderate lameness and distension of the digital flexor tendon sheath in the affected limb. Intrasynovial analgesia of the digital flexor tendon sheath consistently improved the degree of lameness. Ultrasonography most commonly revealed small, distinct, often circular, focal hypoechoic areas within the deep digital flexor tendon which usually extended less than 1 cm proximodistally. The degree of lameness and swelling generally improved with box rest and controlled exercise, however, exacerbation of the clinical signs and ultrasonographic lesions was common when affected horses were returned to work or allowed free exercise at pasture. Of 24 cases, only 7 horses made a full recovery and returned to their intended athletic activity.

[Treatment of multiple metacarpal (tarsal) fractures using a brace in 2 foals and a calf]

The placement of a brace for external fixation of multiple fractures of the carpus or tarsus is described. In these two foals and calf we succeeded in obtaining a combination of good immobilization and full loading of the affected leg.

Metatarsal lengthening by callotasis during the growth phase

Congenital or acquired shortness of a metatarsal may cause pain in adjacent metatarsals. From 1983 to 1990, we performed nine metatarsal lengthenings in seven adolescent patients by metaphyseal osteotomy followed by gradual distraction of callus (callotasis). Two patients required bone grafts after the lengthening. We used a rigid, unilateral external fixator designed for use in the hand and foot. At follow-up, from three to ten years later, healing had been achieved in all with an average healing index of 50 days/cm, and metatarsalgia had been relieved by the restoration of correct metatarsal length.

Unusually located osteoid osteomas

The files of 12 patients (aged 12-33 years) with an equal number of surgically proven osteoid osteomas (OOs) were reviewed in attempt to find a diagnostic algorithm in cases of unusually located OOs. Plain radiography (PR) and thin collimation computed tomography (CT) had been performed in all patients, while bone scintigraphy (BS) had been performed in eight and magnetic resonance imaging (MRI) in two. The OOs were located at juxta- or intra-articular sites, except for one located at the left neck of the L4 vertebra. The diagnosis based on the MRI examinations was synovitis. BS showed increased accumulation of the radioisotope at the site of the lesions, without the 'double density' sign. PR showed the nidus of OO in only six patients, whereas CT located the nidus in all patients. In conclusion, we believe that when an OO is clinically suspected at an unusual location, CT should be performed in all cases, even when a lesion is depicted by PR and BS, because CT will not only locate the nidus but will also provide a precise anatomy of the area around the nidus and help in therapeutic decision making and surgical planning. MRI can be misleading and must not be used in the initial assessment of a possible osteoid osteoma.

Fractures of the proximal fifth metatarsal

Most of the controversy regarding fractures of the fifth metatarsal relates to injuries sustained in the proximal third of the bone. This article serves as an overview of proximal fifth metatarsal fractures, covering the cause, mechanisms of injury, and pertinent anatomy of this injury. The author proposes a classification scheme for fractures of the fifth metatarsal and gives some historical and practical detail with regard to the treatment of each fracture type.

Chevron bone graft procedure for the correction of brachymetatarsia

Brachymetatarsia is a relatively rare condition, although there are many surgical procedures to correct the condition. The authors present a case study with a 2-year follow-up period demonstrating the successful surgical treatment of a 4th metatarsal brachymetatarsia of the left foot of a 14-year-old female. The operative technique and literature review are discussed. This technique combines the idea of bone grafting with a specific graft shape and donor site to facilitate graft stability and graft healing.

Scintigraphic detection of sequential symmetrical metatarsal stress fractures

A patient with complaints of right foot pain and previous normal radiographs had an abnormal three-phase bone scan consistent with a second metatarsal stress fracture. Subsequent radiographs confirmed this diagnosis. Two months later, the patient developed pain in his left foot, and again initial radiographs were noncontributory. A later bone scan revealed a left second metatarsal stress fracture. The results in this case reemphasize the value of bone scintigraphy in patients with foot pain and no bone abnormalities on plain radiographs.

Treatment of brachymetatarsia using a semicircular lengthener. 1-3 years results in 6 patients

6 women with brachymetatarsia involving 9 bones were treated by the use of the Ilizarov semicircular lengthener. The affected bones were the second, third and fourth metatarsals. Ilizarov half-rings were applied on the foot with 5 or 6 half-pins (3 mm in diameter) and a percutaneous osteotomy was done. The short metatarsals were lengthened 0.25 mm twice a day by the patient. The lengthened distance was 15 (10-22) mm and the overall treatment time was 15 (12-25) weeks. The postoperative course was uneventful, with smooth bone regeneration. No bone-grafting was needed. During treatment, the patients could bear full weight and tolerated the fixators well. We conclude that this technique is useful in the treatment of brachymetatarsia.

[Intermediate results following subcapital metatarsal osteotomy in the therapy of hallux valgus with metatarsus primus varus]

71 feet were investigated after subcapital modified osteotomy of the metatarsus according to Kramer for an average follow-up period of 19 months. Mean improvement of the Hallux valgus angle was 10 degrees whereas the intermetatarsal angle was improved by 4 degrees on average. The high degree of satisfaction of patients (83%) with the outcome of this surgical method suggest its application in cases of medium metatarsus primus varus within hallux valgus deformations when the metatarso-phalangeal joint is not affected. In patients aged 50 years and older as well as in cases of MT I varus exceeding 18-20 degrees this operation should strictly be limited to the cases indicated above.

Radiographic geometric variation of equine long bones

As more sophisticated research is performed to refine fracture fixation techniques for horses, it is important that normal values for the geometric properties of the bones of the appendicular skeleton be determined and that suitable controls be available. We evaluated the geometric properties of total bone width, cortical bone width, and medullary canal/trabecular bone width measured from 2 radiographic projections of equine long bones (humerus, radius, third metacarpal bone, femur, tibia, and third metatarsal bone) obtained from a general population of horses. Measurements were performed on slices separated by intervals equal to 5% of the bone's length. Slices were then grouped into 5 regions: proximal epiphysis, proximal part of the metaphysis, diaphysis, distal part of the metaphysis, and distal epiphysis. Results validated use of the contralateral bone as a control for assessing experimental models or clinical cases. Of 858 homotypic slice comparisons between left and right bones, significant (P < or = 0.05) differences were detected in 31 (3.6%) of the comparisons. Of 168 homotypic region comparisons, significant differences were observed in 3 (1.8%) of the comparisons. The greatest variation between left and right bones was observed in metaphyseal regions, areas with bony protuberances, and regions with prominent bone superimposition. At a power of 0.8 for the statistical tests performed in this study, the mean homotypic variation of bones in each region is < 5.8% for the proximal epiphysis, 11.3% for the proximal part of the metaphysis, 6.8% for the diaphysis, 12.2% for the distal part of the metaphysis, and 5.2% for the distal epiphysis.

Radiographic changes in the first metatarsal head after distal chevron osteotomy combined with lateral release through a plantar approach

The purpose of this study was to evaluate the development of clinically significant avascular necrosis of the head of the first metatarsal after: (1) distal metatarsal osteotomy of the chevron configuration beginning apically at the center of the metatarsal head and extending into the head metatarsal neck junction and (2) release of the adductor hallucis muscle, the lateral capsulosesamoid ligament, and the lateral head of the flexor hallucis brevis via fibular sesamoidectomy in the majority of procedures (71/77). Although there were initial radiographic findings suspicious of avascular necrosis, subchondral lucencies (28 feet), mottling (40 feet), and focal lucencies (29 feet) in 76% of the feet, at final follow-up (12-43 months, average 25 months) this figure had fallen to 25%. The range of motion of the first metatarsophalangeal joint and articular symptoms were important in this study because of the assumption that these two parameters of evaluation would correspond to the severity of radiographic evidence of avascular necrosis. Only those patients (8 feet) with persistent mottling at final follow-up had a statistically significant decrease in the average range of motion (P = .013), with 51 degrees total arc of motion compared with 64 degrees total arc of motion for the remainder. There were no patients with persistent radiographic changes suggesting avascular necrosis who complained of pain.(ABSTRACT TRUNCATED AT 250 WORDS)

Hallux valgus, first metatarsal pronation and collapse of the medial longitudinal arch--a radiological correlation

In a previous study we developed a model to assess first metatarsal pronation based on the position of the inferior tuberosity of its base and showed a significant relationship between first metatarsal pronation and the intermetatarsal angle (r = 0.69, p < 0.001). The present study was undertaken to correlate first metatarsal pronation with the height of the medial longitudinal arch in an attempt to define the clinical significance of this new finding. The weight-bearing anteroposterior and lateral radiographs of the feet of 50 patients (100 feet; 36 females patients of mean age 38 years, 14 males patients of mean age 40 years) were reviewed, and in each case, the patient's age, sex, intermetatarsal angle, amount of first metatarsal pronation and medial longitudinal arch angle were recorded by independent observers. A significant relationship was demonstrated between first metatarsal pronation and the height of the medial longitudinal arch (r = 0.93, p < 0.0001). Less marked association was observed between intermetatarsal angles and first metatarsal pronation (r = 0.71, p < 0.001). Multivariate analysis of patient age, sex, intermetatarsal angle and medial longitudinal arch angle against metatarsal pronation showed that the single most dominant variable affecting metatarsal pronation was the height of the medial longitudinal arch.

Basal metatarsal osteotomy for hallux valgus

We performed basal chevron metatarsal osteotomy on 32 feet (31 patients) for painful hallux valgus associated with an increased intermetatarsal 1/2 angle (> 12 degrees). Pedobarographic and radiological examinations were done preoperatively and at a minimum of six months postoperatively. The average hallux valgus angle was improved from 40.9 degrees to 19.2 degrees and the intermetatarsal 1/2 angle from 16.5 degrees to 6.8 degrees. The mean angle of declination of the first metatarsal was decreased by 1.4 degrees. The pedobarographs showed a significant reduction in areas sustaining pressure > 5 kg/cm2, an increased total foot contact area and a higher percentage forefoot contact area on heel raise. There was a high level of patient satisfaction with relief of symptoms and improved appearance of the foot.

Treatment of Freiberg's disease

Freiberg's disease is a relatively rare condition with a multifactorial cause in which trauma and circulation must play a major but not solitary role. Once the condition presents itself, early treatment is geared toward reducing its symptoms and preventing progression. If conservative measures fail, many surgical options are available. One of these, the dorsiflexion osteotomy of the metatarsal head is presented as a logical procedure that is simple, reliable, not destructive, and capable of good results regardless of the stage of the disease.

[Ultrasonographic anatomy and ultrasonographic assessment of the transverse arch of the foot]

A new and original sonographic technique to document the morphology of normal feet and splay feet is presented: a standard sectional plane cuts the transverse arch from the plantar side using the sesamoids of the first metatarsal bone and the head of the fifth metatarsal bone as reference points. A 5-MHz linear transducer and a rather simple custom-made platform with an integrated gel-pad are required in order to get reproducible results. The morphology of the transverse arch can be characterized by the "transverse arch index Q" as the parameter of the relative height of the transverse arch. Based on this transverse arch index Q, splay feet can be distinguished from normal feet in a statistically significant way (p < 0.01). Furthermore, grading of splay feet is possible and a documentation of rigidity/flexibility of the forefoot in splay feet; thus, the decision on whether to use conservative or operative treatment can additionally be based on sonographic documentation, and the results of surgical reconstruction of the transverse arch can be checked and documented sonographically.

Metatarsus proximus and digital divergence. Association with intermetatarsal neuromas

A retrospective radiologic study was performed to determine whether there is an increased finding of metatarsus proximus and digital divergence in patients with a confirmed diagnosis of intermetatarsal neuroma when compared with an asymptomatic group. The study included 48 patients with pathologic confirmation of neuroma and 100 asymptomatic patients. Results of the study revealed no statistical relationship between the radiologic findings of metatarsus proximus and digital divergence and the physical occurrence of neuromas. An unexpected finding was an increased intermetatarsal angle of the affected interspace in the neuroma group.

Brachymetatarsia. Axial lengthening by using the callus distraction technique

The authors present a modified approach to the ilizarov callus distraction technique for bone lengthening on a patient with brachymetatarsia. This approach has certain advantages and disadvantages that will be discussed along with historical methods of treating brachymetatarsia. The actual case history, surgical technique, and perioperative care of the patient are described in detail.

Heritability estimations of osteochondrosis in the tibiotarsal joint and of bony fragments in the palmar/plantar portion of the metacarpo- and metatarsophalangeal joints of horses

Radiography of the tibiotarsal and metacarpo- and metatarsophalangeal joints was performed on 753 Standardbred trotters (6 to 21 months old) born in 1988. The surveyed population was drawn at random from all parts of Norway and represented about 60% of Standardbred trotters born the same year. Osteochondrosis in the tibiotarsal joint was diagnosed in 108 (14.3%) horses, and the prevalence of disease in progeny groups > 10 ranged from 0 to 69%. Bony fragments in the palmar/plantar portion of the metacarpo- and metatarsophalangeal joints were diagnosed in 89 (11.8%) horses, and the prevalence of disease in progeny groups > 10 ranged from 0 to 41%. Heritability analysis was restricted to 644 horses, comprising groups of 5 or more progeny, from 39 stallions. The heritabilities of osteochondrosis in the tibiotarsal joint and of bony fragments in the palmar/plantar portion of the metacarpo- and metatarsophalangeal joints were estimated to be 0.52 and 0.21, respectively, using a nonlinear model.

Jones' fracture

The Jones' fracture is defined as a transverse fracture of the proximal fifth metatarsal diaphysis within 1.5 cm of the tuberosity. It is classified radiographically as acute, delayed union and nonunion. Some orthopedists also have added a classification of stress fractures. The best form of treatment is based on the presence or absence of medullary sclerosis adjacent to the fracture site. In addition, the prescribed treatment must be adhered to by the patient to prevent increased morbidity associated with this fracture.

An investigation of injection techniques for local analgesia of the equine distal tarsus and proximal metatarsus

A positive radiographic contrast agent was injected into the tarsometatarsal (TMT) joints of both hindlimbs of 10 horses. Lateromedial radiographic views were obtained at 5, 15 and 30 mins after injection. Injection was successful in 19 of 20 limbs. Communication between the centrodistal (CD) and TMT joints was identified in 7 limbs (35%). Contrast agent extended around the tendons of tibialis cranialis (TC) and fibularis tertius (FT) in 18 limbs, and in 7 limbs some contrast entered the tarsal sheath. Slight to moderate plantar and/or distal extension of contrast agent was identified in 13 limbs. On a subsequent occasion positive contrast agent was injected subtarsally using one of two techniques and radiography was repeated. Contrast agent was principally distributed on the plantar aspect of the 3rd metatarsal bone, the plantar aspect of the suspensory ligament and between the superficial and deep digital flexor tendons. Extension of contrast agent into the TMT joint was identified in only 1 limb but in 8 limbs contrast agent extended into the tarsal sheath. The practical implications of these results include the possibility that local anaesthetic solution injected into the TMT joint may alleviate pain from the CD joint, the insertions of TC and FT or the tarsal sheath. It may also result in perineural analgesia of the dorsal metatarsal nerves or the plantar metatarsal nerves. In some cases subtarsal injection of local anaesthetic solution may result in alleviation of pain from the tarsal sheath. False negative results for subtarsal analgesia may be achieved by inadvertent injection into the tarsal sheath or into a blood or lymphatic vessel.

Metatarsal epiphyseal bracket: treatment by central physiolysis

Longitudinal epiphyseal bracket (LEB) is a rare ossification anomaly in which an epiphysis brackets the diaphysis of a phalanx, metacarpal, or metatarsal. This abnormal epiphysis tethers longitudinal growth, resulting in a shortened and oval-shaped bone. Four patients with five LEBs were treated by central physiolysis and followed for a mean of 6 years. The patients had significant hallux varus deformity. Three patients had duplicated great toes, and two had tibia hemimelia significant enough to require epiphysiodesis as they neared adolescence. Resection of the LEB allowed the proximal and distal epiphysis to resume untethered growth. Silastic or methyl methacrylate was placed over the resected physis to prevent bony rebridging. The associated hallux varus deformity was corrected by capsulorrhaphy and K-wire fixation. In all patients, the metatarsal resumed longitudinal growth and correction of the hallux varus was maintained.

The offset V modification of the Chevron bunionectomy: a retrospective study

This is a retrospective study of two different types of fixation for the offset-V modification of the Chevron (Austin) bunionectomy for correction of hallux abducto valgus deformity. Both screw fixation and Kirschner wire fixation were evaluated radiographically for hallux abductus angle, intermetatarsal angle, proximal articular set angle, tibial sesamoid position, and first metatarsal length. In addition, charts were reviewed for complications selective to each type of fixation. Radiographically, there was no apparent difference in preoperative and postoperative measurements between the two types of fixation. However, chart review led the authors to conclude certain advantages to screw fixation, in terms of clinical results and patient satisfaction.

Structural metatarsus adductus deformity, surgical case report

Structural metatarsus adductus deformity may be corrected through the use of closing abductory base wedge osteotomies of all five metatarsals. Although technically demanding, surgical precision is increased through the use of oblique wedges and a combination of screw and cerclage wire fixation. In the severe case, an opening wedge osteotomy of the inner cuneiform (Fowler procedure), with homogenous bone implantation, may be concomitantly used. Both techniques are described in this brief case presentation.

Giant cell tumor in skeletally immature patients

The radiographs and clinical and surgical histories of 50 skeletally immature patients with histologically verified giant cell tumor (GCT) of the long and short tubular bones were retrospectively studied to determine the prevalence, location within bone (eg, epiphysis, metaphysis), skeletal distribution, radiographic appearance, and pathogenesis of GCTs. Skeletal immaturity was determined radiographically by the presence of open epiphyses. Patients were selected from a group of 876 patients who were seen in consultation with documented GCT of the tubular bones. Approximately 5.7% of all GCTs occurred in the skeletally immature (this rate must be viewed with caution due to the selection bias inherent in any referral population). The lesions almost invariably involved the metaphysis. The tibia was the most commonly affected site, representing approximately 26% of cases. All were geographic lytic lesions, with margins ranging from sclerotic to ill defined. An expanded (widened), remodeled bone contour was frequently encountered. Approximately 56% of lesions were solid or solid with cystic change; the remaining 44% were predominantly cystic.

[A simple method for repositioning metatarsal fractures]

Because of small direct contact to the fracture fragments reduction of metatarsal fractures can be achieved only indirectly by applying traction to the toes. In this article a method for simple direct manipulation of the distal main fragment of metatarsal fractures is described: A K-wire is drilled in dorsi plantar direction across the head of the fractured metatarsal and mounted on a traction bow. In this manner the distal fracture fragment can be moved in all directions and placed exactly onto the proximal fragment. All 8 patients with multiple metatarsal fractures could be treated by closed reduction and percutaneous pinning. The described method allows simple and precise reduction of metatarsal fractures, reduced x-ray exposure of the surgeon's hand by short operation times, and manipulation for fracture reduction outside the x-ray beam.

Case report 713. Chondromyxoid fibroma of the third metatarsal

In the case presented, the imaging features are those of an aggressive benign or less aggressive malignant lesion. The differential diagnosis radiographically included aneurysmal bone cyst with or without an accompanying lesion, giant cell tumor synovial sarcoma, and other mesenchymal sarcomas. Indeed, at times it is difficult to be certain whether the process originated in the bone or soft tissue. Pathological examination of the resected specimen showed the typical features of chondromyxoid fibroma. Grossly, the tumor was well demarcated and firm and composed of tan, translucent tissue that destroyed cortex but was confirmed by periosteum. Histologically, the tumor consisted of myxoid, chondroid, and fibrous elements. The tumor lobules were composed of predominately myxoid matrix containing stellate cells. Variable chondroid elements were present with immature appearing chondrocytes, containing eosinophilic cytoplasm and irregularly shaped nuclei.

[Surgical treatment of hallux valgus by peg osteotomy]

Authors describe a method of therapy of hallux valgus not yet published in this country. Its advantage is that as a consequence of the shortening of the proximal phalanx the tension of the soft tissues is decreased and as a final result the movement occurs between the original cartilaginous surfaces.

[Management of metatarsalgia using Helal's method for metatarsal osteotomy]

Authors report on the result of Helal's metatarsal osteotomies performed on 62 feet of 48 patients for metatarsalgia. In 85 per cent the result proved to be excellent, in 15 per cent there was no improvement. Analysing the causes of the postoperative complaints they call attention to the overload of the marginal arches and to the metatarsalgia developing on the non osteotomized neighbouring arch. These complaints appeared in 1/3 of their material and could be generally well influenced with conservative treatment.

[Value of osteotomy of the proximal end of the metatarsal base in Köhler II disease]

Authors briefly describe the etiology of Köhler II. disease and the possibilities of the operative treatment. The osteotomy of the proximal end of the metatarsus, performed by them, the biomechanical basis of the operation, the indication are detailed and the favourable experiences gained with this procedure are reported.

Observer variability in the radiographic measurement and classification of metatarsus adductus

The classification system of Berg was evaluated using four observers and the radiographs of 42 feet from patients with metatarsus adductus. Interobserver disagreement in diagnosis was 36%. Intraobserver inconsistency averaged 26%. The error range for the lateral and anteroposterior talocalcaneal angle measurement was 13.6 and 15.1 degrees intraobserver and 19.8 and 25.2 degrees interobserver, respectively. There was no correlation between classification and the length of time required for cast correction. The irregularity of hindfoot ossification centers makes measurements inconsistent and seriously reduces the usefulness of classification based on such measurements.

Iselin's disease

Iselin's disease (traction apophysitis of the tuberosity of the fifth metatarsal) has been reported rarely, but is probably more common than appreciated. It appears to be more common in athletically active older children and adolescents. Four patients with this condition were treated conservatively and all had resolution or improvement of symptoms. In one, however, nonunion developed and continues to cause intermittent pain at age 20 years. Early recognition and treatment may prevent long-term complications.

Comparison of Chevron osteotomy and modified McBride bunionectomy for correction of mild to moderate hallux valgus deformity

The purpose of this study was to compare the results of the Chevron osteotomy to the DuVries' modification of the McBride procedure using identical criteria in two groups of patients. Thirty-two patients (48 feet) that had a Chevron osteotomy and 10 patients (17 feet) who had a modified McBride bunionectomy without metatarsal osteotomy for treatment of mild to moderate hallux valgus were retrospectively reviewed using subjective and objective criteria. Both groups were matched according to age, severity of deformity, and length of follow-up. Ninety-two percent of patients in the Chevron group and 88% of patients in the McBride group responded that they were either totally satisfied or improved regarding pain relief and appearance of the foot following surgery. Chevron osteotomy resulted in a statistically significant greater correction of the intermetatarsal 1-2 angle than did the McBride bunionectomy. Postoperative metatarsophalangeal joint range of motion was not significantly different for the two groups. Following Chevron osteotomy, five (10%) metatarsal heads exhibited radiographic changes of cyst formation and/or increased osteodensity and three (6%) of the osteotomies healed in a malunited position. One of the three metatarsal head malunions occurred in a patient that also had a lateral capsular release, however, none of the five cases that developed radiographic changes in the first metatarsal head was associated with a lateral capsular release. Lateral capsular release with the Chevron osteotomy did not improve the amount of correction of the hallux valgus deformity and it may be a contributing factor to instability at the osteotomy site leading to a valgus malunion.

Simple bunionectomy with medial capsulorrhaphy

Bunionectomy with medial capsulorrhaphy was performed on 54 feet (37 patients) and follow-up was obtained on 49 feet (33 patients) at a mean of 4.8 years postoperatively. Results were excellent in 17 feet, good in 16, fair in 7, and poor in 9. Mean motion of the first metatarsophalangeal joint was 81 degrees. The primary reason for failure was recurrent deformity. Patients were dissatisfied with the results in 41% of the feet. Mean intermetatarsal 1-2 angle increased 1.7 degrees and mean metatarsophalangeal-1 angle increased 4.8 degrees. The operation was significantly more successful in patients who underwent it for painful medial eminence. Bunionectomy with medial capsulorrhaphy is recommended for elderly patients with symptoms primarily due to prominent medial eminence, and its application for the young patient with significant hallux valgus deformity is limited.

Basal osteotomy of the fifth metatarsal for the bunionette

A proximal basal chevron osteotomy was carried out on 20 patients (22 feet) with a Tailor's bunion deformity. The follow-up was of a minimum of 3 years for all patients. Direct surgery on the fifth metatarsophalangeal joint for bunionette treatment has often been unsuccessful and there have been recurrences due to metatarsophalangeal instability. Basal osteotomy is therefore preferred. The patients were satisfied. The intermetatarsal 4-5 angle was noticeably reduced. There were no postoperative complications and no recurrences. The fifth metatarsophalangeal joint was corrected despite the absence of direct surgery and remains stable. This operation is recommended for acute bunionettes with intractable plantar keratosis.

Juvenile hallux valgus with compensated metatarsus adductus. Case report

The authors describe a case report of a patient with compensated metatarsus adductus and juvenile hallux valgus bilaterally. Treatment included closing base wedge abductory osteotomies of metatarsals one through five, modified McBride bunionectomy, Evans calcaneal osteotomy, and a percutaneous tendo Achillis lengthening. The patient maintained excellent correction on the right foot after 6 years. Hallux valgus recurred on the left foot after 2 years. The authors attribute this recurrence to a significant internal femoral torsion on the left leg. The significance of superstructural deformities on juvenile hallux valgus is discussed.