Metatarsal osteotomy in rheumatoid arthritis

Thirty-eight feet in 28 patients with rheumatoid forefoot deformity were operated on with a proximal valgus osteotomy of the first metatarsal bone to reduce splaying of the forefoot. Each patient also underwent additional surgical procedures for associated conditions of the forefoot. The mean follow-up period was 3.7 years. Both the entire forefoot and the medial border of the foot were substantially improved in all but 2 cases. Residual symptoms were slightly more pronounced in the anterior footpad and the lesser toes (5 cases). A proximal valgus osteotomy of the first metatarsal bone, performed in combination with other surgical procedures, affords a good correction of the rheumatoid foot deformity with long-term improvement.

Basal osteotomy of the fifth metatarsal with intermetatarsal pinning: a new approach to tailor's bunion

The direct approach to the fifth metatarsophalangeal joint for the treatment of metatarsus quintus valgus often has been unsuccessful, mainly because of technical difficulties in the osteotomy of the narrow fifth metatarsal neck and the fixation of the unstable head fragment. Complications such as delayed union, nonunion, or recurrence have been reported. This paper describes a surgical technique for optimal correction of this deformity. The technique has a biomechanically sound fixation and a shortened bone healing time with minimum complications. Results of 12 patients presenting severe deformities are reported, with 1-year average follow-up.

[Osteoblastoma of the 1st metatarsal bone. Apropos of a case]

Metatarsal localisation of osteoblastoma is rare. We report a case of a sixteen years old girl. The foot was swollen but unpainful. The plain film showed an extensive, osteolytic tumor of the whole of the first metatarsal bone. The radiological diagnosis could be discussed with an aneurysmal cyst, a chondroma, a desmoplastic fibroma, a fibrous dysplasia, an angioma. The total resection was possible without opening of the tumor and reconstruction was possible with a tibial graft. The pathological diagnosis was benign osteoblastoma. Recovery was uneventful.

Nuclear scintigraphic evaluation of third metacarpal and metatarsal bone fractures in three horses

Nuclear scintigraphy was used to evaluate healing of third metacarpal bone (MC III) fractures in 2 horses (horses 1 and 2) and a third metatarsal bone fracture in 1 horse (horse 3) after stabilization of each fracture with 2 broad dynamic compression plates. In horse 1, the fracture had uniform uptake of 99mTc methylene diphosphonate on days 1, 15, and 30 after surgery. The fracture healed, and the horse was discharged from the clinic on day 52. In horse 2, a 6-cm photopenic region (ie, area of low radioactivity) was seen over the diaphysis of MC III on day 3. The region persisted and became more distinct by day 32. The diaphysis of MC III sequestered, and horse 2 was euthanatized on day 44. In horse 3, vascularity was seen bridging the fracture on day 5, with a 3-cm photopenic region over the dorsal diaphysis of the third metatarsal bone. By days 18 and 32, uptake of 99mTc methylene diphosphonate in the region had increased, indicating vascularization of the site. the fracture healed, and horse 3 was discharged from the clinic on day 47. Our findings indicated that serial nuclear scintigraphy can be used to evaluate fracture vascularization after surgery in horses.

Distal metatarsal osteotomy for hallux valgus in the middle-aged patient

Thirty-eight distal metatarsal osteotomies for hallux valgus in middle-aged patients between the ages of 50 and 67 years were performed over a period of five years. None of the patients could be rated with an excellent result. Good results were noted in only 52.6%. Poor results were attributable to imperfect surgical technique, severity of preoperative deformity, osteoporosis, and preexisting osteoarthritic changes at the first metatarsophalangeal joint.

Metatarsus primus elevatus and the etiology of hallux rigidus

One hundred twenty radiographs of the foot were evaluated for hallux abductus angle, lateral talometatarsal angle, and metatarsus primus elevatus position. Mean elevatus position of the first metatarsal above the second metatarsal was approximately 7.0 mm. First ray elevation was a consistent finding in all data groups studied, including controls. The presence of hallux abducto valgus or hallux rigidus did not affect the degree of first ray elevation present. The majority of radiographs studied lacked evidence of joint disease. Therefore, the common practice of evaluating radiographic elevatus as a surgical criteria to predict the possible development of hallux rigidus should be strongly discouraged.

The late results of tarsometatarsal joint injuries

The late results of tarsometatarsal injuries in 33 patients have been reviewed. The average follow-up period was 15 years (range 11 to 20 years). Methods of treatment included cast immobilisation, and closed or open reduction with or without internal fixation. All patients noted diminishing symptoms after injury and all but six returned to their former occupation. Neither the initial fracture type nor the treatment had any apparent bearing on subsequent function; nor was there any correlation between radiographic assessment of the injury and the patient's symptoms.

Scintigraphic manifestations of infraction of the second metatarsal (Freiberg's disease)

Two patients with Freiberg's infraction of the second metatarsal are presented. The scintigraphic pattern of a photopenic defect with hyperactive collar is demonstrated as evidence of the existence of avascular necrosis or infarction in this entity. The photopenia was appreciated only on pinhole collimator images in our first patient. The later revascularization phase of avascular necrosis with diffuse increase in uptake is demonstrated scintigraphically in the second patient.

Surgical management of metatarsus adductus deformity

This article is intended to provide the podiatric physician with a comprehensive overview of the surgical management of metatarsus adductus deformity. Both soft tissue and osseous procedures are reviewed including a practical discussion of the preferred incisional approaches, surgical techniques, and postoperative care. Current indication and concepts for each procedure are discussed. A comprehensive history and physical exam, with emphasis on the clinical evaluation and radiographic findings, are critical aspects in the management of the patient with metatarsus adductus. Selection of procedures will be based upon this information as well as chronological age and osseous maturity. When significant deformities in the rearfoot complex are present (that is, pes valgo planus, equinus), consideration should be given to surgical correction simultaneously with correction of the forefoot deformity or at a later stage.

Radiographic evaluation in the pediatric patient

A brief overview of the radiographic evaluation of the pediatric foot has been presented. Experience in evaluating the normal foot is a mandatory prerequisite for identifying pathology in the pediatric foot. Specific radiographic techniques have been discussed to enhance the evaluation of individual pathologies in different age groups. Correlation of clinical and radiographic findings is as essential in the pediatric patient as it is in the adult.

The radiographic and histologic appearance of controlled surgical manipulation of the equine periosteum

This study documented the normal histologic features of the equine metacarpal and metatarsal periosteum and characterized its osteogenic response to surgical manipulation. Two periosteal flaps were elevated from the dorsomedial matacarpal and metatarsal diaphysis in each of three limbs of four yearling and four adult lightbreed horses. The superficial metacarpal cortex under the flap was resected with a bone chisel in one-half of the horses and was undisturbed in the remainder. One periosteal flap in each limb was excised and the other flap was replaced and secured by sutures. All limbs in the horses were radiographed at regular intervals postoperatively. Horses were killed either 30 or 120 days after surgery. Periosteal bone production occurred only at treatment sites of young horses treated by periosteal flap replacement and was limited to approximately 50% of these sites, as determined by radiography and microradiography. Cortical abrasion resulted in an increased incidence of bone production in the periosteum adjacent to the flap perimeter. The histologic features of the periosteum were similar to those reported in other species; young horses had active osteogenesis referable to appositional growth and adults had an inactive periosteum. Histologically, osteogenesis induced by surgery resembled accentuated appositional growth in both yearlings and adults. In the horse, the cambial (osteogenic) layer is included in sharply elevated periosteal flaps. It should be removed in surgical procedures where bone production is to be avoided, and preserved where osteogenesis is desired.

A normal variant simulating Freiberg's disease

Radiologic examination of the feet was performed in 72 normal persons with no history or physical signs of disease of the feet. In about 10 per cent, bilateral flat configuration of the second metatarsal head accompanied by a joint space wider than in the neighbouring joints was found, and is therefore a normal anatomic variant that must not be confused with Freiberg's disease or its final stages.

Surgical management of tarsal coalition in adolescent athletes

The authors studied 12 adolescent patients with a known diagnosis of tarsal coalition. These patients were also active participants in athletics. Of the 12 patients studied, there were eight with calcaneonavicular bars and four with talocalcaneal bars. Even though nonoperative treatment was not successful, only eight of the 12 elected to have surgery. Following surgical resection of the tarsal coalition, five of six patients who had calcaneonavicular bar excisions as well as two patients with talocalcaneal bar excisions were able to return to competitive athletics. Nonoperative treatment of the tarsal coalition did not result in alleviation of symptoms and full return to athletics. The surgical excision of the calcaneonavicular bar with extensor digitorum brevis arthroplasty afforded the best results.

A reappraisal of metatarsus adductus and skewfoot

The hypothesis that the treatment of adduction of the fore part of the foot in the child is altered by an associated deformity of the middle or the hind part, or both, was tested in a prospective study of eighty-four patients (124 feet). Radiographic classification delineated four configurations of adduction of the foot, based on varying relationships of the fore, middle, and hind parts of the foot. Twenty-two (43 per cent) of the feet with adduction of the fore part alone (simple metatarsus adductus) required no treatment, as compared with eighteen feet (24 per cent) with the other types of adduction (p less than 0.03). The patients with a complex skew-foot deformity required twice as long a period of cast treatment as those with simple metatarsus adductus (p = 0.0001). On evaluation at a minimum follow-up of two years, only one of the 124 feet had residual adduction of the fore part of the foot, as determined radiographically. It was also found that the use of the Denis-Browne bar was accompanied by an increased incidence of flat-foot deformity at follow-up.

Elongation of brachymetatarsy with ceramic implant: a roentgenographic evaluation of its utility

The metatarsal bone was elongated by intercalary implantation of a single-crystal alumina ceramic in 7 patients with brachymetatarsy. The implants were encased with new bone 24 months after surgery and resulted in 5.2 to 9.2 mm elongation of the metatarsal bone. The response of the bone to the ceramic implant was observed roentgenographically. No resorption or pseudoarthrosis of the bones, nor loosening or breakage of the implants, were observed. The alumina ceramic implant proved to be a useful substitute for a bone graft, because of its biocompatibility and strength.

Metacarpal and metatarsal fractures in dairy cattle: 33 cases (1979-1985)

Metacarpal (22) and metatarsal (11) fractures in 33 dairy cattle were treated by application of short or full limb casts. Twelve fractures involved the distal physis (6 closed, 6 open) and 21 fractures were nonphyseal (17 closed, 4 open). All physeal fractures were noncomminuted and 11/12 were classified as Salter-Harris type II. Eleven (52%) of nonphyseal fractures were comminuted. Closed fractures were reduced and a cast was applied after manual restraint, sedation with xylazine (along with use of ropes), or general anesthesia. Open fractures were best treated with the cow under general anesthesia. These fractures were carefully debrided, lavaged, and reduced, and a cast was applied. Antibiotics and analgesics were given parenterally. All cattle were restricted to a box stall during fracture healing. Fracture healing generally was rapid and uncomplicated. No closed fracture perforated the skin. Fracture healing was characterized radiographically by extensive circumferential periosteal new bone growth, closure of the distal physis, and preservation of articulations adjacent to the fracture site. Follow-up ranged from 6 to 78 months (mean, 32 months). Thirty of 33 (91%) cattle survived for a long period. All cows with closed (23) and 7 of 10 (70%) with open fractures survived. Three cows were euthanatized; 2 developed severe osteomyelitis and one fractured her metatarsus above a short cast. All 30 surviving cattle were considered by their owners not lame on the previously injured limb, with no noticeable angulation, bowing, or shortening. No deleterious effects on milk production were detected.

Surgical correction of tailor's bunion with resection of fifth metatarsal head and silastic sphere implant: an 8-year follow-up study

This paper introduces a fifth metatarsal head surgery with silicone sphere implant to correct tailor's bunion deformities and prevent digital retraction that may occur after fifth metatarsal head resection. The authors present an 8-year follow-up of 35 patients who underwent 50 procedures. The authors had an 84% success rate, but they submit that this procedure is not indicated in every case of tailor's bunion.

Opening base wedge osteotomy of the first metatarsal utilizing rigid external fixation

The authors describe their operative approach to metatarsus primus adductus deformity when present in conjunction with a congenitally short first metatarsal. Hallux abducto valgus correction in this clinical setting has traditionally advocated use of a crescentic or opening wedge osteotomy in order to prevent further shortening of the first metatarsal. Fixation of opening base wedge osteotomies has been fraught with problems in the past, with possibilities for displacement or eventual loss of initial correction. The authors have found the mini-Hoffmann external fixation device useful for this purpose.

[Osteonecrosis of the child's foot]

On the basis of defined diagnostic elements, numerous conditions described in the literature as osteonecrosis are divided up into rare and questionable forms of osteonecrosis, on the one hand, and distinguished from definite, spontaneous osteonecrosis form the other. The clinical and radiological characteristics are often in agreement with the course of the disease. These aspects are presented and the more up-to-date studies on the etiology are cited. The two forms of definite, spontaneous osteonecrosis of the foot in children are described extensively, and typical courses are illustrated.

Polyarthropathy associated with Cushing's disease

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