[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.