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.