Correction method for moderate and severe degrees of hallux valgus associated with transfer metatarsalgia

BACKGROUND

Hallux valgus (HV) is a common foot deformity that manifests with increasing age, especially in women. The associated foot pain causes impaired gait and decreases quality of life. Moderate and severe HV is a deformity that is characterized by the involvement of lesser rays and requires complex surgical treatment. In this study, we attempted to develop a procedure for this condition.

AIM

To analyse the treatment results of patients who underwent simultaneous surgical correction of all parts of a static forefoot deformity.

METHODS

We conducted a prospective clinical trial between 2016 and 2021 in which 30 feet with moderate or severe HV associated with Tailor's bunion and metatarsalgia were surgically treated via a new method involving surgical correction of all associated problems. This method included a modified Lapidus procedure, M2M3 tarsometatarsal arthrodesis, intermetatarsal fusion of the M4 and M5 bases, and the use of an original external fixation apparatus to enhance correction power. Preoperative, postoperative, and final follow-up radiographic data and American Orthopaedic Foot and Ankle Society (AOFAS) scores were compared, and P values < 0.05 were considered to indicate statistical significance.

RESULTS

The study included 28 females (93.3%) and 2 males feet (6.7%), 20 (66.7%) of whom had a moderate degree of HV and 10 (33.3%) of whom had severe deformity. M2 and M3 metatarsalgia was observed in 21 feet, and 9 feet experienced pain only at M2. The mean follow-up duration was 11 months. All patients had good correction of the HV angle [preoperative median, 36.5 degrees, interquartile range (IQR): 30-45; postoperative median, 10 degrees, IQR: 8.8-10; follow-up median, 11.5 degrees, IQR: 10-14; P < 0.01]. At follow-up, metatarsalgia was resolved in most patients (30 vs 5). There was a clinically negligible decrease in the corrected angles at the final follow-up, and the overall AOFAS score was significantly better (median, 65 points, IQR: 53.8-70; vs 80 points, IQR: 75-85; P < 0.01).

CONCLUSION

The developed method showed good sustainability of correction power in a small sample of patients at the one-year follow-up. Randomized clinical trials with larger samples, as well as long-term outcome assessments, are needed in the future.

Muscle strength and foot pressure vary depending on the type of foot pain

This study compared muscle strength and foot pressure among patients with metatarsalgia, patients with plantar fasciitis, and healthy controls. A total of 31 patients with foot pain (14 metatarsalgia and 17 plantar fasciitis) and 29 healthy controls participated in the study. The strengths of the plantar flexor and hip muscles were measured using isokinetic and handheld dynamometers, respectively. Foot pressure parameters, including the pressure-time integral (PTI) and foot arch index (AI), were assessed using pedobarography. Compared with the healthy control group, plantar flexor strength was significantly reduced in the affected feet of the metatarsalgia and plantar fasciitis groups (F = 0.083, all p < 0.001); however, hip strength was significantly decreased only in the affected feet of the metatarsalgia group (F = 20.900, p < 0.001). Plantar flexor (p < 0.001) and hip (p = 0.004) strength were significantly lower in the metatarsalgia group than in the plantar fasciitis group. The PTI was lower in the forefeet of the affected feet in the metatarsalgia (p < 0.001) and plantar fasciitis (p = 0.004) groups. Foot AI (p < 0.001) was significantly reduced only in the metatarsalgia group. These results suggest the need to consider the evaluation of muscle strength and foot pressure in both feet for the diagnosis and treatment of foot pain.

Safety and Efficacy of Percutaneous Morton Neuroma Cryoneurolysis Under Ultrasound Guidance

PURPOSE

To assess the technical success, safety and early efficacy of Morton neuroma (MN) cryoneurolysis.

MATERIALS AND METHODS

Retrospective review of 54 consecutive patients with MN treated with cryoneurolysis after failure of conservative treatment, from September 2022 to June 2023. Outcomes measurements included technical success (defined a successful ultrasound-guided placement of the cryoprobe), procedural safety according to Cirse classification and change in 6 months post-procedure by pain numeric rating scale (pNRS).

RESULTS

A total of 59 MN were treated during 55 procedures. Mean procedure duration was 47 min, all patients were discharged 2 h after the intervention. Technical success was 98.1%. No Cirse grade 3, 4 or 5 complication was reported. Three grade 2 complication occurred, including two chilblain-type lesions and one bone insufficiency fracture. At 6 months post-procedure, pNRS score was significantly decreased (2.7 ± 2.2 vs 7.1 ± 1.1) (p < 0.0001), with a mean score decrease of 4.1points. Thirty-two patients (60.4%) reported a complete pain relief, 15 (28.3%) a partial pain relief and 6 (11.3%) no pain relief, or increased pain.

CONCLUSION

Cryoneurolysis seems to be safe for the treatment of Morton neuroma. Six-month pain relief is promising and needs to be confirmed at long term.

Lateral metatarsal osteotomy

Lateral metatarsal osteotomy (LMO) aims to reposition the affected metatarsals in a chosen position. The approach may be open or percutaneous. There are several types of LMO, according to displacement: shortening, raising, translation or lengthening. Preoperative planning covers type and extent of displacement, osteotomy location and type (open or percutaneous), and number of metatarsals concerned. In the 1990s, older concepts of non-fixed osteotomies gave way to preoperative planning and calculated shortening, including the development of Weil shortening osteotomy. Diaphyseal lengthening or shortening osteotomy is mainly used for brachymetatarsia. The older concept of non-fixed lateral rays made a comeback with percutaneous first-ray surgery. Distal metatarsal minimally invasive osteotomy (DMMO) is the most effective, giving rise to variants such as distal oblique metatarsal minimally invasive osteotomy (DOMMO), to meet the requirements of greater displacement, especially in shortening and translation, and to be applicable in as wide a range of cases as possible. Presently, these percutaneous techniques have not demonstrated superiority over open surgery, and entail specific complications. Even so, they are now part of the armamentarium of forefoot surgery, as their minimal invasiveness corresponds to current trends in surgery, especially in the foot. Level of evidence: V.

Clinical and biomechanics effects of modified Helal osteotomy with screw fixation in forefoot reconstruction

PURPOSE

The object of this study was to assess the efficacy of Helal metatarsal osteotomy with screw fixation in patients with hammertoe deformities.

METHODS

Thirty-five patients (66 feet, 66 metatarsals) with hammertoe deformity underwent Helal osteotomy with screw fixation after first ray reconstruction. Pre- and postoperative AOFAS scale results, podobarometry (in-shoe plantar pressure), and X-ray (angular) parameters were analyzed. The patients were examined before the operation and two, six, and 24 months postoperatively.

RESULTS

The average AOFAS score was 59 (± 2.4) preoperatively and 96 (± 1.2) in 12 months after the operations. Pressure under the second and third metatarsal heads was decreased from 396 (± 52.3) kPa preoperatively to 240 (± 22.3) kPa 12 months postoperatively. Lateral subluxation of the second and third toes before the operation was observed in 62 (94%) feet, average metatarsophalangeal angle was 28.1 (± 3.3) degrees. While it was not found in any case 12 months after operation, in four (6.1%) feet, it became recurrent 24 months postoperatively; the average metatarsophalangeal angle was 5° (± 0.6).

CONCLUSION

Helal osteotomy with screw fixation demonstrated good-to-excellent results in 24 months postoperatively. It allows for a three-dimension lesser rays reconstruction: shortening, elevating, and lateral or medial displacement of the metatarsal head.

Orthopaedic and plastic surgery collaboration in resolution of plantar heloma and metatarsalgia using lipofilling: a retrospective evaluation

BACKGROUND

Plantar heloma is a keratotic disorder that can be described as a circumscribed area of thickening with a central core that may penetrate the dermis. Although often considered a minor complaint, longstanding lesions can be debilitating and severely impact on person's quality of life. We present the first retrospective case series at long-term follow-up about the use of plantar lipofilling as a treatment for metatarsalgia caused by plantar heloma.

MATERIALS AND METHODS

Six patients affected by plantar heloma associated to external metatarsalgia underwent plantar lipofilling. The surgical session was performed as an outpatient procedure. Clinical evaluation was performed using the AOFAS lesser metatarsophalangeal-interphalangeal (MTP-IP) score.

RESULTS

Mean AOFAS lesser MTP-IP score improved from a preoperative score of 66.6 ± 3.2 points (range 47-77 points) to a post-operative score of 92.8 ± 2.7 points (range 86-95 points); all patients were satisfied with the outcome at the final follow-up. Post-operative clinical examination at final follow-up showed an increase in thickness of the subcutaneous layer and a decrease of dermal layer thanks to the supporting and trophic action of fat cells.

CONCLUSIONS

Plastic regenerative procedures applicated to a typical foot and ankle surgery field, such as metatarsal overloading, metatarsalgia and forefoot problems, should be encouraged to allow new treatment horizons.

Comparison of modified Mitchell and Chevron osteotomies for hallux valgus

BACKGROUND

Good clinical and radiological outcomes in mild-moderate hallux valgus (HV) can be achieved with Chevron osteotomy (CO) and modified-Mitchell osteotomy (MMO). The main goal of the present study was to compare the clinical and radiological outcomes after CO and MMO in HV.

METHODS

The study included 45 patients, comprising 40 females with a mean follow-up of 87.5 ± 27.8 months. The outcome measurements of metatarsal length (MT1), HV angle (HVA), intermetatarsal angle (IMA), clinical outcomes, and metatarsalgia were evaluated pre- and postoperatively.

RESULTS

No significant difference was determined between the MMO and CO groups in respect of metatarsalgia and AOFAS scores. The CO resulted in a significantly larger decrease in the MT1. The mean HVA and IMA correction was significantly greater after MMO than after CO.

CONCLUSION

Since MMO may prevent MT1 shortening, which is a typical problem in the Mitchell osteotomy, MMO may be preferred over CO in patients with preoperative shortened first metatarsal.

[Minimally invasive forefoot surgery: concept and techniques]

Minimally invasive surgery (MIS) has advanced to an established approach in the correction of all deformities of the forefoot. For the first ray the minimally invasive chevron and Akin osteotomy (MICA) shows very good clinical results and provides a broad spectrum of indications in comparison to the classical chevron osteotomy. The minimally invasive treatment of hallux rigidus also seems to achieve comparable results to the open techniques, although the surgical indications must be thoroughly evaluated. Lesser toe deformities are often easier to treat with minimally invasive osteotomy, capsule release and tendon lengthening than with complex open procedures and usually do not require any internal fixation material. Compared to the classical Weil osteotomy, distal metatarsal osteotomy shows a reduced rate of cock-up deformities and does not require internal fixation. In relation to open procedures, minimally invasive approaches should be accepted as a valuable addition and alternative to the classical open techniques due to the reduced rate of wound healing disorders and postoperative pain.

Hallux valgus with second metatarsalgia: Is second metatarsal Weil osteotomy necessary?

BACKGROUND

The role of concomitant Weil osteotomy to address second toe metatarsalgia during hallux valgus correction is unclear. We aimed to critically analyse outcomes of an additional Weil osteotomy versus isolated Scarf osteotomy.in the management of hallux valgus and second metatarsalgia.

METHODS

Patients with second toe metatarsalgia who underwent first metatarsal Scarf osteotomy for hallux valgus were enrolled retrospectively. Demographics, radiographic measurements and functional outcomes were assessed at baseline, 6-months and 2-years postoperatively. Between-group significance was established with Fisher exact test, Chi-square or Mann-Whitney U test. Within-group changes from baseline were assessed with paired t-test and Wilcoxon signed-rank test.

RESULTS

48 feet (34 isolated Scarf, 14 concomitant Weil osteotomy) were included. Both cohorts demonstrated significant improvements across all measures of functional outcome. However, patients with additional Weil osteotomy reported poorer short-term outcomes.

CONCLUSION

Superiority of additional Weil osteotomy versus isolated Scarf osteotomy in addressing second toe metatarsalgia or improving functional outcomes was not demonstrated.

Patient reported outcomes following revision neurectomy through a dorsal approach for recurrent interdigital neuroma

Interdigital neuroma is one of the commonest causes of metatarsalgia. The reported success rate after excision of a primary neuroma is 74%. Recurrent symptoms after neurectomy can be due to a recurrent interdigital neuroma. Recurrent interdigital neuromas can be diagnosed using sound clinical examination and ultrasonography. Surgical excision is the best treatment modality with varying success reported in the literature. We report on the clinical outcome following surgical excision of recurrent interdigital neuromas through a dorsal approach. All patients who had undergone excision of a recurrent interdigital neuroma by a single surgeon between 01/2010 and 12/2019 were identified. Inclusion criteria included patients having a preoperative ultrasound and postoperative histology report. The exclusion criteria were preexisting neuropathy or tarsal tunnel syndrome. Demographic data was collected, and a self-reported foot and ankle score questionnaire (SEFAS) was completed by the patient at their most recent follow-up. Twenty-three patients (25 feet) were included in the study. Mean time of follow-up was 75 (range 14-189) months. The mean age was 49 (range 15-71) years. Eleven (44%) recurrent neuromas were excised from the second webspace and 14 (56%) were excised from the third webspace. All excised masses were confirmed as recurrent neuromas histologically. Regarding the SEFAS score, 17 (73.93%) patients scored as excellent, one (4.34%) as good, three (13.04%) as fair, and two (8.69%) as poor. This long term follow-up study on outcomes after surgery for recurrent interdigital neuroma suggests that excision through a dorsal approach is an effective treatment option with a high patient satisfaction.

Percutaneus intermetatarsal ligament release and minimally invasive distal metatarsal osteotomy for treatment second intermetatarsal space syndrome

BACKGROUND AND OBJECTIVE

Since the description of the syndrome of the second intermetatarsal space, this is a common diagnosis among foot and ankle surgeons. However, no series have been published that consider this syndrome as its own entity. The objective of this study is to evaluate the clinical and radiological results of the release of the intermetatarsal ligament and minimally invasive distal metatarsal osteotomy in patients diagnosed with second space syndrome.

MATERIALS AND METHODS

An observational, longitudinal, retrospective study was carried out in patients with a clinical diagnosis of second space syndrome operated on using a minimally invasive technique. For the clinical results, the visual analog scale (VAS) for subjective pain, the Manchester-Oxford Foot Questionnaire (MOXFQ) and the scale for minor metatarsals and interphalangeals of the American Orthopedic Foot and Ankle Society (AOFAS-LMTS) were used for clinical-functional assessment. Consolidation or not of osteotomies was recorded and complications were recorded.

RESULTS

Twenty-nine feet in 29 patients were included in the study. After a mean follow-up of 39 months (25-50), clinically and statistically significant improvement was obtained in the scores: pain VAS, scales and subscales of the MOXFQ and the AOFAS-LMTS (p < 0.0001). All osteotomies healed at the end of follow-up and no major complications were recorded.

CONCLUSIONS

Percutaneous or minimally invasive surgery, in patients with second intermetatarsal space syndrome, obtains good clinical, functional and subjective results, with few complications. Therefore, we consider it an effective, safe and recommended technique in the hands of experienced surgeons.

Risks of injury in distal metatarsal minimally invasive osteotomy when comparing standard and modified techniques: A cadaveric study

BACKGROUND

The objectives of the study were to evaluate the structures at risk in distal metatarsal mini-invasive osteotomy (DMMO) and to compare standard and intraosseous approaches.

METHODS

DMMO was performed on the second and fourth metatarsals of 11 fresh-frozen cadaveric specimens. The standard technique was performed in 11 metatarsals. It was then compared to a modified intraosseous technique that entails starting inside the bone in 11 other metatarsals. The cadavers were dissected to identify unintentional injury to soft tissue structures.

RESULTS

In the standard group the most injured structures were the metatarsal joint capsules (MJC) (27%), extensor digitorum longus (EDL) (18%), and extensor digitorum brevis (EDB) (9%). The modified intraosseous group injured the EDL (27%), not the MJC (0%) and the EDB (0%). Distances between osteotomies and the dorsal metatarsal head articular surface (DMHAS) were 6.08 ± 3.99 mm in the standard and 9.92 ± 3.42 mm in the modified (p = 0.02).

CONCLUSION

The DMMO techniques most frequently injured the EDL. Intra-articular positioning of the osteotomy was more observed in the standard. Overall, it appears the modified method could be an alternative to the standard DMMO.

CLINICAL RELEVANCE

The modified minimally invasive DMMO has a comparable rate of potential iatrogenic injuries. This intraosseous procedure may present as an option when planning surgery to the lesser metatarsals.

LEVEL OF EVIDENCE

Level III. Comparative Cadaveric Study.

Distal Metatarsal Osteotomies for Chronic Plantar Diabetic Foot Ulcers

In more than 30 years of scientific literature (1986-2021), the few published studies on the management of CPDFUs by DMOs showed satisfactory clinical and radiographic outcomes. Although these reports were all case series, their data suggest that DMOs, performed at a different level of the distal metatarsal bones, are an effective surgical treatment option for achieving rapid healing of CPDFUs and preventing their recurrence after balancing the pressures in diabetic forefeet. Hence, DMOs can be a valid alternative treatment method also for CPDFUs with chronic infection, ulcers penetrating deep structures, and even ulcers with osteomyelitis at the metatarsophalangeal level.

Comparison of the Forefoot Pressure-Relieving Effects of Foot Orthoses

PURPOSE

Metatarsal pads are prescribed to decrease forefoot plantar pressure. However, the appropriate metatarsal pad placement location remains a debated issue. We aimed to identify the most effective insole design that reduces forefoot plantar pressure and determine the optimal position for metatarsal pad placement.

MATERIALS AND METHODS

We recruited 16 healthy adult volunteers, and measured their plantar pressure data during walking while using an in-shoe system. The volunteers were randomly assigned to one of four insole conditions: 1/16-inch insole (i.e., control), 1/4-inch soft plastazote (SP) flat insole, metatarsal pad positioned proximal to the metatarsal head (MTH) on the control insole (P0), and metatarsal pad positioned 10 mm distal from the proximal border of the MTH on the control insole (P10). A masking protocol was created by dividing the forefoot into three subareas, distal to the MTH (dMTH), beneath to the MTH (bMTH), and proximal to the MTH (pMTH). The participants reported their comfort level for each insole using a visual analog scale.

RESULTS

The SP flat insole and metatarsal pads both had a forefoot plantar pressure-reducing effect and provided insole comfort. Of the three insole designs, the SP flat insole was the most effective. No clear difference existed in efficacy in terms of the location of the metatarsal pad placement.

CONCLUSION

Considering the possibility of discomfort caused by improper metatarsal pad placement, the SP that increases shock absorption may be more clinically useful.

Operative Management: Plantar Plate

The plantar plate is a vital structure for maintaining lesser metatarsophalangeal joint (MPJ) stability. Its primary role is to provide static stabilization of the MPJs, working in conjunction with the long and short flexor and extensor tendons. When insufficiency or attenuation of the plantar plate occurs, a sagittal plane deformity will slowly develop, eventually leading to a "crossover toe" transverse plane deformity. Coughlin coined this descriptive term to describe the later stages of deformity, most commonly affecting the second MPJ. Shortly after, Yu and Judge elaborated on this condition describing it as "predislocation syndrome," an inflammatory condition affecting the plantar plate causing pain and instability, which could progress to subluxation at the MPJ.

Long-term comparison between blind and ultrasound-guided corticoid injections in Morton neuroma

OBJECTIVES

This work compares the effectiveness of blind versus ultrasound (US)-guided injections for Morton neuroma (MN) up to 3 years of follow-up.

METHODS

This is an evaluator-blinded randomised trial in which 33 patients with MN were injected by an experienced orthopaedic surgeon based on anatomical landmarks (blind injection, group 1) and 38 patients were injected by an experienced musculoskeletal radiologist under US guidance (group 2). Patients were assessed using the visual analogue scale and the Manchester Foot Pain and Disability index (MFPDI). Injections consisted of 1 ml of 2% mepivacaine and 40 mg triamcinolone acetonide in each web space with MN. Up to 4 injections were allowed during the first 3 months of follow-up. Follow-up was performed by phone calls and/or scheduled consultations at 15 days, 1 month, 45 days, 2 months, 3 months, 6 months and 1, 2 and 3 years. Statistical analysis was performed using unpaired Student's t tests.

RESULTS

No differences in age or clinical measures were found at presentation between group 1 (VAS, 8.5 ± 0.2; MFPDI, 40.9 ± 1.1) and group 2 (VAS, 8.4 ± 0.2; MFPDI, 39.8 ± 1.2). Improvement in VAS was superior in group 2 up to 3 years of follow-up (p < 0.05). Improvement in MFPDI was superior in group 2 from 45 days to 2 years of follow-up (p < 0.05). Satisfaction with the treatment was higher in group 2 (87%) versus group 1 (59.1%) at 3 years of follow-up.

CONCLUSION

Ultrasound-guided injections lead to a greater percentage of long-term improvement than blind injections in MN.

KEY POINTS

• Ultrasound-guided corticosteroid injections in Morton neuroma provide long-term pain relief in more than 75% of patients. • Ultrasound-guided injections in Morton neuroma led to greater long-term pain relief and less disability than blind injections up to 3 years of follow-up. • The presence of an ipsilateral neuroma is associated with worse long-term disability score.

Ultrasound-guided distal minimally invasive metatarsal osteotomies (US-DMMO): A cadaveric study about its safety and accuracy

BACKGROUND

Distal minimally invasive metatarsal osteotomies have become increasingly popular. This technique requires fluoroscopic control, but recently, an ultrasound-guided procedure has been described. The aim of this anatomical study was to assess the quality safety of ultrasound-guided minimally invasive metatarsal osteotomies.

METHODS

Ultrasound-guided distal minimally invasive metatarsal osteotomies were performed in 9 cadaveric pieces. The location of the osteotomy, its angulation, and the adjacent anatomical structures injuries was evaluated RESULTS: Thirty-six osteotomies were performed. The osteotomy was metaphyseal in 97.2% of the cases, the average angulation was 47.67° (±4.49, 40-59°) and the average distance to the articular cartilage was 3.22 mm (±1.27, 1-7 mm). One osteotomy (2.8%) was intraarticular and there was one joint capsule lesion (2.8%). The failure, the extreme point distance and angulation values, and the joint capsule injury correspond to a fifth metatarsal.

CONCLUSIONS

The ultrasound-guided technique is safe and allows a correct location and angulation of the osteotomies.

Effectiveness of the Fixtoe Device® in plantar pressure reduction: a preliminary study

Background

Metatarsalgia is a common foot condition. The metatarsophalangeal stabilizing taping technique described by Yu et al. has shown good clinical results as a provisional treatment in propulsive metatarsalgia. ³⁵ The Fixtoe Device®, a novel orthopedic device, intends to simulate stabilizing tape. However, to date, there is no evidence of its effectiveness. The aim of this study was to assess plantar pressure changes using the Fixtoe Device®, in comparison with the traditional method (stabilizing tape) in a young, healthy sample thorough a cross-sectional study.

Methods

Maximal pressure (Kpa) and pressure–time integral (Kpa/s) in the second metatarsal head were measured in twenty-four healthy volunteers. Registers were taken in four different conditions: barefoot, traditional stabilizing tape, Fixtoe Device® without metatarsal pad, and Fixtoe Device® with metatarsal pad.

Results

Mean second metatarsal head maximal pressure and mean pressure–time integral showed statistical difference among the four analyzed conditions (p < 0.0001 in both cases). The improvement in maximal pressure and pressure–time integral obtained in each intervention also showed significance (p < 0.0001 in both cases). Comparing the improvement of the Fixtoe Device® with and without metatarsal pad with that of tape condition showed a moderate to high and moderate effect size for both peak pressure and pressure–time integral reduction.

Conclusions

The Fixtoe Device® reduces median maximal pressure and median pressure–time integral under the second metatarsal head in healthy young individuals. The Fixtoe Device® shows higher effectiveness than the traditional second metatarsophalangeal joint stabilizing taping technique. To our knowledge, this is the first investigation proving the effectiveness of the recently developed Fixtoe Device® in terms of plantar pressure modification, which leads the way to its use in clinics.

A versatile method for dorsal-approach plantar plate repair using standard operative instruments

Background

The plantar plate is an important static stabilizer of the lesser metatarsophalangeal joints, and disruptions of the plantar plate can lead to significant instability and lesser toe deformities. In recent years, direct plantar plate repair has been proposed. Although direct repair via a dorsal approach is attractive, a torn plantar plate is small and difficult to access using regular instruments in a restricted operative field.

Methods

In this report, a unique method for plantar plate repairs was used to repair various configurations of plantar plate tears with standard operative instruments that are available in most operating rooms.

Results

Using this method, 10 patients underwent plantar plate repairs, and the mean follow-up period was 24 (range, 14–38) months. The mean visual analog scale score for pain preoperatively was 4.1 (range, 0–6) and decreased to 0.6 (range, 0–3) at last follow-up. Postoperatively, the mean visual analog scale score for satisfaction was 9.6 (range, 8–10) and the mean American Orthopedic Foot and Ankle Society forefoot score was 88.8 (range, 75–100).

Conclusions

Our study proposes an inexpensive and versatile method for plantar plate repair via a dorsal approach that uses standard operative instruments.

Trial registration

ClinicalTrials.gov, NCT04949685. July 2, 2021 - Retrospectively registered,

Level of clinical evidence

4

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04951-w.

A problem-based approach in musculoskeletal ultrasonography: central metatarsalgia

Ultrasonography (US) is a useful diagnostic method that can be easily applied to identify the cause of metatarsalgia. The superficial location of structures in the foot, dynamic capability of US, and the ability to perform direct real-time evaluations of the pain site are also strong advantages of US as a modality for examining the foot. Moreover, knowing the possible pain sources to investigate when a patient has a specific site of pain will enhance the diagnostic quality of US, and will help radiologists to perform US efficiently and effectively. The purpose of this article is to review the common etiologies of metatarsalgia including Morton’s neuroma, plantar plate injury, synovitis, tenosynovitis, bursitis, and metatarsal fractures, and to discuss their US features.

Does screwless scarf osteotomy for hallux valgus increase the risk of transfer metatarsalgia?

INTRODUCTION

The scarf osteotomy is a reliable surgical technique for treating hallux valgus. The aim of our study was to analyze the occurrence of transfer metatarsalgia after surgery on the first ray using a screwless Scarf osteotomy technique that we have been using in our department since 1995, which consists of stabilization by axial impaction without internal fixation. We hypothesized that the alleged shortening of the first metatarsal produced by this technique may be at the origin of postoperative metatarsalgia.

PATIENTS AND METHODS

This was a case series of first ray metatarsal screwless Scarf osteotomies reviewed in the medium term. We did a clinical and radiological review of all patients operated using this technique between 2012 and 2017 who did not meet the following exclusion criteria: procedure on the other lateral metatarsals, concurrent hindfoot pathology, incomplete medical records.

RESULTS

Of 114 feet, 96 were included in the study and 18 were excluded. The mean follow-up was 1 year and 8 months [1-4years]. The mean AOFAS score was 90.3 and 96% of patients were either satisfied or very satisfied with the outcome. All the parameters improved significantly: shoe wearing, pain, function, alignment. Fourteen feet had transfer metatarsalgia, which appeared during the first year postoperative (AOFAS 75/100). Ten other complications occurred: two Morton's neuromas, three cases of complex regional pain syndrome, one superficial infection, one paresthesia, two recurrences with surgical revision, one nonunion. No general complications were found. Based on radiographs, the mean M1 shortening was 3.3mm (6.3mm in metatarsalgia group versus 3.0 mm in the non-metatarsalgia group, P=0.2) and the mean angular correction was 16.2° (±6°).

DISCUSSION

The overall results of screwless Scarf osteotomy are comparable and satisfactory, allowing large deformities to be corrected (28°±8° preoperatively in our cohort). M1 shortening and the transfer metatarsalgia rate appear to be higher than with other techniques.

CONCLUSION

Screwless scarf osteotomy of M1 yields good functional and radiological outcomes in the medium term. However, it appears to cause more shortening and transfer metatarsalgia.

LEVEL OF EVIDENCE

IV Retrospective, non-interventional in current practice (Recommendation grade C, low level of scientific proof).

Imaging in metatarsalgia

Metatarsalgia is a common clinical conundrum that requires careful assessment. There are a variety of causes and understanding these can help manage the pain. These causes have different imaging characteristics and require specific imaging. By understanding core imaging principles and how they apply to causes of metatarsalgia, pathology can be more efficiently investigated. This article covers primary, secondary and iatrogenic causes of metatarsalgia with the most appropriate imaging modalities for each and the salient imaging findings. This article reviews the common forefoot pathologies and how they may be optimally radiologically investigated, with an emphasis on the key imaging findings.

[Clinical results of treatment of mechanical metatarsalgia without first metatarsal involvement]

OBJECTIVE

To analyze the clinical results of metatarsalgia treated with percutaneous distal metatarsal metaphyseal osteotomies (DMMO).

MATERIAL AND METHODS

Prospective and continuous study of 29 patients with isolated unilateral mechanical metatarsalgia, operated on with DMMO, with a mean follow-up of 38 months. The mean age of the patients was 58 (range: 50-67) years and only two men. We use the AOFAS score, we obtained the digital and metatarsal formulas on the X-rays. We record the subjective assessment of the surgeon and the patient at the end of the treatment.

RESULTS

The improvement in the final score exceeded 80 points in all cases (p = 0.000), with a significant improvement in pain (p = 0.000) and calluses (p = 0.000), improving metatarsal-phalangeal joint stability and interphalangeal and metatarsal alignment. The type of footwear did not change after surgery, we found no variation in mobility, neither in the metatarsophalangeal joints (p = 0.382), nor in the interphalangeal joints (p = 0.672). After surgery increased the square foot morphology (p = 0.027) but the metatarsal formula underwent few modifications. Patients and surgeons were in 96% of the cases "very satisfied" or "satisfied".

CONCLUSION

DMMO achieves a high degree of satisfaction in patients and in the surgeon, pain and hyperkeratosis under the head of the painful metatarsals disappear and that significantly improves the functional capacity of patients.

Shortening effect influence of Distal Minimally Invasive Metatarsal Osteotomy in primary metatarsalgia

PURPOSE

In primary metatarsalgia, Distal Minimally invasive Metatarsal Osteotomy (DMMO) achieves a correct load distribution which is a factor in pain relief, but contrary to the elevation of the metatarsal head, shortening the metatarsal length has no influence on plantar-loading parameters, while the increased metatarsal length is a factor in the development of metatarsalgia. Thus, we hypothesized that metatarsalgia could be partly related to a functional imbalance between bone structure and soft tissues and pain relief after DMMO results from soft tissue relaxation.

METHODS

Many authors have highlighted the correlation between joint pressure and periarticular soft tissue tension. To test our hypothesis, we measured intra-operatively the MTPJ pressure of 19 patients suffering from primary metatarsalgia, before and after DMMO. This pressure is being analyzed as a reflection of joint decompression and forefoot soft tissue release. Many authors have highlighted the correlation between joint pressure and periarticular soft tissue tension.

RESULTS

Lower metatarsals presenting metatarsalgia show a significantly lower MTPJ pressure compared to asymptomatic rays, and DMMO induces a significant increase of MTPJ pressure.

CONCLUSION

Those variations reflect the functional imbalance between bone structure and soft tissue in primary metatarsalgia. The biomechanical rationale of the shortening effect of DMMO could therefore be explained by the release of forefoot soft tissue, which could take part in the pain relief by restoring this balance.

Plantar pressure distribution in hallux valgus feet after a first metatarsal proximal crescentic osteotomy with a lesser metatarsal proximal shortening osteotomy

BACKGROUND

Plantar pressure distribution after the first metatarsal proximal crescentic osteotomy (FMPCO) with lesser metatarsal proximal shortening osteotomy (LMPSO) for hallux valgus with metatarsalgia has not been previously described.

METHODS

The pre- (Pre) and postoperative (Post) groups comprised of 18 patients who underwent unilateral FMPCO with LMPSO; fifteen healthy volunteers constituted the control (C) group. For each of the 10 regions, peak pressure (Peak-P), maximum force (Max-F), contact time (Con-T), contact area (Con-A), and force-time integral (FTI) were measured.

RESULTS

The mean Peak-P of the second metatarsal head was significantly lower in the Post group than the Pre group. The mean Peak-P, Max-F, Con-T, and FTI were not significantly different between the Post and C groups. The mean Con-A was significantly lower in the Post group than the C group.

CONCLUSION

FMPCO with LMPSO may improve the plantar pressure of the central forefoot comparable to healthy subjects.

Ultrasound findings of plantar plate tears of the lesser metatarsophalangeal joints

Lesser metatarsophalangeal (MTP) joint plantar plate tears are a common and increasingly recognised cause of metatarsalgia, MTP joint instability and forefoot deformity. Increased interest in early accurate diagnosis of plantar plate tears follows recent surgical innovations allowing direct plantar plate repair. The purpose of this review is to describe the ultrasound features of normal lesser MTP joint plantar plates and to characterise and illustrate the direct and indirect ultrasound findings of plantar plate tears. Lesser MTP joint plantar plate tears are most commonly located at the 2nd MTP joint, involving the lateral distal plantar plate insertion with variable propagation medially and proximally. The most common ultrasound appearance of a plantar plate tear is a discrete partial or full thickness hypoechoic defect in the plate substance. Flattening and attenuation or non-visualisation of the plantar plate represent more extensive tears. Dynamic imaging with toe dorsiflexion improves visualisation of tears and augments MTP joint subluxation. A common indirect finding is pericapsular fibrosis along the MTP joint capsule adjacent to a plantar plate tear, which requires differentiation from Morton's neuroma, and key distinguishing features at ultrasound are described. Other indirect findings include the cartilage interface sign, flexor tendon subluxation onto the metatarsal head or medial to the midline, flexor tenosynovitis, proximal phalangeal enthesophytes or avulsion and MTP joint synovitis. Ultrasound offers several advantages over MR imaging but requires a meticulous ultrasound examination, and optimisation of scanning technique is described.

Plantar forefoot pain: ultrasound findings before and after treatment with custom-made foot orthoses

PURPOSE

No prior studies investigated the role of ultrasound in the assessment of response of patients undergoing treatment of metatarsalgia with custom-made orthoses. Our aim was to describe ultrasound findings of patients with plantar forefoot pain treated with custom-made foot orthoses.

METHODS

Twenty patients (15 females; mean age: 62.6 ± 11 years) affected by metatarsalgia in 27/40 feet underwent clinical evaluation before, three months and six months after treatment with custom-made full foot insole with a support proximal and an excavation below the painful metatarsals. Ultrasound was performed before and three months after the use of orthoses to examine the presence of intermetatarsal/submetatarsal bursitis, metatarsophalangeal joints effusion, anterior plantar fat pad oedema, flexor tendinitis/tenosynovitis, and Morton's neuroma. Outcome measures were clinical response with Foot Function Index (FFI)/Visual Analogue Scale (VAS) and ultrasound features changes.

RESULTS

Median VAS and FFI before treatment were 8[5-8.5] and 45.85[32.4-59.4], respectively. After 3 and 6 months of insoles use, both median VAS (2.5 [0-5] and 0 [0-2.75], respectively) and median FFI (7.9 [3.95-20] and 0 [0-3.95], respectively) showed a significant reduction in pain and disability (p < .001). Before treatment, ultrasound revealed 22 intermetatarsal bursitis, 16 submetatarsal bursitis, 10 joint effusions, 20 fat pad oedema, 3 flexor tendinitis/tenosynovitis and 3 Morton's neuromas. After 3 months of treatment, a significant decrease of intermetatarsal bursitis (7, p < .001) was observed. No significant changes were observed in any other ultrasound parameters.

CONCLUSION

Ultrasound might be able to detect some imaging features associated with the response of forefoot pain to custom-made foot orthoses, especially intermetatarsal bursitis.

Distal Metatarsal Minimally Invasive Osteotomy (DMMO): Surgical technique, variants, indications, and treatment decision-tree

BACKGROUND

Metatarsal osteotomy is a major means of treating mechanical metatarsalgia. Open techniques are widely used, and notably that described by Weil. They have, however, certain drawbacks, and new types of osteotomy have been developed. Percutaneous techniques are presently very much in favor, and Distal Metatarsal Minimally Invasive Osteotomy (DMMO) has emerged as a treatment for metatarsalgia. Although very widely used, it is poorly codified in the literature.

METHOD

The present study detailed DMMO techniques and their variants (oblique and reverse), with corresponding indications and treatment decision-tree.

RESULTS

Initial findings seem encouraging, with functional results comparable to those of open surgery. Postoperative edema and radiologic bone healing time seem to be longer in DMMO. There is, on the other hand, no difference regarding stiffness.

CONCLUSION

DMMO is an effective option to treat metatarsalgia, with variants enabling adaptation to foot morphology, but needing confirmation by studies with higher levels of evidence.

Hallux valgus with and without metatarsalgia in women: a matched-cohort study of plantar pressure measurements

BACKGROUND

Few previous studies focused on plantar loading patterns in HV patients with metatarsalgia. Are there any differences in plantar pressure measurements in women with HV with and without metatarsalgia?

METHODS

A prospective matched-cohort study was designed to analyze plantar pressure measurements in women with HV with and without metatarsalgia from January 2017 to December 2019. The inclusion criteria were age over 18 years old, women, diagnosis of HV with metatarsalgia. Control group had the same inclusion criteria, except metatarsalgia. Patient-reported outcomes scores included American Orthopedic Foot and Ankle Society Score (AOFAS), and Visual Analog Scale (VAS). Radiographic data were obtained according to the guidelines of the AOFAS Committee on Angular Measurements. Plantar pressure measurements were performed using a platform.

RESULTS

Forty-seven patients met the inclusion criteria. An age-, BMI-, and hallux valgus angle-matched cohort of 47 patients were also selected. There were no statistically significant differences in demographic data and radiographic assessment. HV with metatarsalgia group showed greater values in peak and mean force, peak and mean pressure, and pressure-time integral under toes and metatarsal heads. These differences reached statistically significant in mean force (p = 0.009) and peak force (p = 0.003) under T1; mean pressure (p = 0.01) and peak pressure (p = 0.04) under T1; and mean force (p = 0.003) under MH1. The binary logistic regression analysis showed mean force under T1 as the most associated plantar pressure measurement with the presence of metatarsalgia. C-statistic was 0.66. Mean force > 35 N had a 70% of sensitivity and a 57% of specificity as a cut-off value for the presence of metatarsalgia.

CONCLUSION

HV patients with metatarsalgia had greater values in plantar pressure measurements. Mean force under T1 could be used as a plantar pressure measurement to predict metatarsalgia.

[Reconstruction of the plantar plate of the metatarsophalangeal joint using a dorsal transarticular approach]

OBJECTIVE

Reconstruction of the plantar plate to stabilize a dislocated or instable lesser metatarsophalangeal joint using a dorsal approach in combination with a Weil osteotomy.

INDICATIONS

Dislocated or instable lesser metatarsophalangeal joint with rupture of the plantar plate.

CONTRAINDICATIONS

Infection, circulatory disorders, symptomatic degenerative arthritis lesser metatarsophalangeal joint.

SURGICAL TECHNIQUE

Weil osteotomy using a dorsal approach. Temporary dislocation of the metatarsal head as proximal as possible. Inspection of the plantar plate. Assessment and classification of type and extent of the rupture. Suturing of the plantar plate to the plantar bases of the proximal phalanx. Fixation of the Weil osteotomy with correction of the metatarsal alignment.

POSTOPERATIVE MANAGEMENT

Weight bearing in a postoperative shoe as tolerated. X‑ray control 6 weeks postoperative. Full weight bearing in a conventional shoe after bony consolidation.

RESULTS

A total of 23 surgical reconstructions of the plantar plate (complete plantar plate repair) between 12/2012 and 10/2014 were performed. The mean follow-up was 18.6 (12-30) months. Five secondary dislocations were observed: one deep postoperative infection, one early dislocation of unknown cause, one secondary dislocation caused by severe hallux valgus recurrence, one massive foreign body reaction to the non-resorbable sutures, and one late secondary dislocation occurred between 6 weeks and 1 year postoperative. Normal function of the reconstructed joint was achieved in 13 of the 23 reconstructions (57%). A reduced toe purchase was observed in 3 reconstructions (13%). A floating-toe resulted after 7 reconstructions (30%).

Scarf osteotomy for hallux valgus deformity: Radiological outcome, metatarsal length and early complications in 118 feet

BACKGROUND

Scarf osteotomy has been widely used to restore axial orientation of the first ray in the treatment of hallux valgus deformity. The aim of the study was to present our radiological outcomes of bunion reconstruction, identify surgical complications in early follow-up, and assess to what extent a shortening of the first metatarsal is present after surgery as a possible cause of postoperative metatarsalgia.

METHODS

We enrolled 106 patients (118 feet) and assessed patients' pre- and postoperative measurements of hallux valgus and intermetatarsal angles on weightbearing X-ray images. Three different methods of measuring metatarsal length were compared and early postoperative complications noted.

RESULTS

Hallux valgus angle decreased significantly by an average of 18.7 degrees and the intermetatarsal angle by 7.8 degrees. Using three methods of measuring metatarsal length, all showed significant shortening of the first metatarsal. Mean relative lengthening of the second metatarsal averaged 0.45mm. The Coughlin method showed the highest interrater reliability (ICC=0.96).

CONCLUSIONS

Significant reduction of the hallux valgus angle and intermetatarsal angle was demonstrated with a low complication rate. There was significant shortening of the first metatarsal. The Coughlin method clearly demonstrated an excellent interrater reliability.

LEVEL OF EVIDENCE

Level IV.

Tips, quips and pearls: Ultrasound-guided distal metatarsal minimal invasive osteotomy (US-DMMO)

Metatarsalgia is a frequent cause of forefoot pain. Surgical treatment is based on the performance of osteotomies at the level of the minor radii to restore a normal distribution of pressure within the forefoot and improve the biomechanics during gait. In recent years, percutaneous surgery of the foot, and specifically distal metatarsal minimal invasive osteotomy, have proven to be a valid technique, providing satisfactory clinical results, similar to open osteotomy with less soft tissue aggression, but it requires intraoperative fluoroscopy to be performed. This article will present a modification to guide the procedure by ultrasound providing a new option that eliminates radiation and provides greater portability and accessibility.

Effect of toe exercises and toe grip strength on the treatment of primary metatarsalgia

Background

The relationship of metatarsalgia and toe function is poorly understood. We investigated the efficacy of toe exercises for the treatment of metatarsalgia.

Methods

Forty-one (56 feet) metatarsalgia patients (mean age ± SD: 63.4 ± 10.6) underwent toe strength measurement. We recorded pre- and post-treatment VAS score, AOFAS score, marble pickup, single-leg standing time (SLST), and compared in two subgroups to evaluate impact of disease duration on treatment outcome.

Results

Post treatment, toe plantarflexion strength improved (all p < 0.01); VAS scores decreased (p < 0.01); AOFAS scores, marble pickup, and SLST improved (all p < 0.01). Patients symptomatic for > 1 year had significantly lower changes in VAS scores (p < 0.01). Multivariate analysis showed patients with longer disease duration, and larger body mass index had significantly lower improvement in VAS scores (p = 0.029 and p = 0.036, respectively). Device consistency assessed by ICC was excellent (0.89–0.97).

Conclusion

Toe function and metatarsalgia are improved by toe exercises, suggesting that they are closely related.

First ray alignment in Lapidus arthrodesis - Effect on plantar pressure distribution and the occurrence of metatarsalgia

BACKGROUND

Lapidus arthrodesis is an established treatment option for severe hallux valgus deformity especially in patients suffering from instability of the first tarsometatarsal joint. Surgery related metatarsalgia is known to be associated with persistent elevation of the first ray after realignment surgery. Nevertheless, detailed information on ideal positioning of the first ray in Lapidus surgery is missing so far. This study was designed to determine any correlations between radiographic and pedobarographic outcome following the Lapidus procedure with regard to clinical outcome and the occurrence of metatarsalgia.

METHODS

Thirty feet (28 patients) after Lapidus surgery were available for follow-up at 42.5±21.0 months. All subjects had radiographic and pedobarographic evaluation of the operated foot and patient satisfaction was recorded using questionnaires.

RESULTS

Metatarsalgia was associated with a poorer outcome in FADI and AOFAS scores (p<0.005). A lateral shift of plantar pressure distribution to the third metatarsal head in these cases could be observed. Although Lapidus surgery resulted in significant shortening of the first metatarsal, no correlation to the occurrence of metatarsalgia was detectable. Likewise, axial plane malalignment showed no influence, whereas elevation of the first ray was highly correlated to surgery related metatarsalgia (p=0.007). Subjects suffering from metatarsalgia had a higher BMI (body mass index), but its effect on metatarsalgia turned out not to be significant (p=0.090).

CONCLUSION

In Lapidus surgery realignment of the first metatarsal in the sagittal plane seems to be decisive for good clinical outcome. Failing to plantarflex the arthrodesis resulted in a lateral shift of plantar loading with overload of the lesser metatarsals and the occurrence of metatarsalgia.

Treatment of metatarsalgia based on claw toe deformity through soft tissue release of the metatarsophalangeal joint and resection of the proximal interphalangeal joint: Evaluation based on foot kinematics and plantar pressure distribution

INTRODUCTION

This study investigated the effect of operative claw toe correction with release of the metatarsophalangeal (MTP) joint, repositioning of the plantar fat pad and resection of the proximal interphalangeal joint on foot kinematics, plantar pressure distribution and Foot Function Index (FFI).

METHODS

Prospective experimental study with pretest-posttest design. The plantar pressure, 3D foot kinematics and the FFI of 15 patients with symptomatic claw toes were measured three months before and 12months after surgery. Mean pressure, peak pressure and pressure time integral per sensor and various foot angles were calculated for the pre- and posttest and compared to a control group (N=15).

RESULTS

Claw toe patients have increased pressure under the distal part of the metatarsal head and less pressure under the proximal part of the metatarsal heads compared to healthy controls. After surgery, there was a redistribution of pressure, resulting in a significant decrease of pressure under the distal part and an increase under the proximal part of the metatarsal head, providing a more equal plantar pressure distribution. Except for some small areas under the forefoot, heel and toes, there were no significant differences in pressure distribution between the operated feet and controls. Small, but significant differences between the pre- and postoperative condition were found for the lateral arch angle, calcaneus/malleolus supination and tibio-talar flexion. The score on the FFI improved statistically significant.

DISCUSSION

These findings imply that the present operative procedure results in a more equal distribution of the plantar pressure under the forefoot and decrease of pain and offers successful treatment of metatarsalgia based on claw toe deformity.

Minimally Invasive Surgery: Osteotomies for Diabetic Foot Disease

Minimally invasive distal metatarsal diaphyseal osteotomy (DMDO) is an effective procedure for the treatment of complicated chronic diabetic foot ulcers under the heads of all lateral metatarsal bones (including the fifth). Resistant toe ulcers and recurrent pressure ulcers can be treated effectively by DMDO. For diabetic patients, the main advantages of this method are minimal surgical scars and tissue damage, immediately postoperative weight bearing, absence of osteosynthesis and consequent potential infection of metal fixation, reduction of the previous high plantar pressures by the restoration of a harmonic balanced forefoot arch, and rapid ulcer healing.

MIS Distal Metatarsal Metaphyseal Osteotomy in the treatment of metatarsalgia: MOXFQ patient reported outcomes

INTRODUCTION

The aim of this paper is to present validated patient reported outcomes for MIS Distal Metatarsal Metaphyseal Osteotomy (DMMO) in the treatment of metatarsalgia. The study aims to evaluate the DMMO procedure, report patient satisfaction with the operated foot and report any complications of this procedure.

PATIENTS AND METHODS

Between 2014 and 2016, patients who had failed conservative treatment for metatarsalgia were identified in the orthopaedic outpatient clinic. Twenty four consecutive patients requiring DMMO plus/minus toe straightening were prospectively studied. Patients requiring additional procedures at the time of surgery were excluded. Patients completed the validated Manchester-Oxford Foot Questionnaire (MOXFQ) three weeks pre-operatively and 1 year postoperatively. The MOXFQ results were analysed using Paired t-tests. A supplementary question was asked regarding patient satisfaction with the operated foot.

RESULTS

There were 20 women and 4 men with a mean age of 64 years (sd 8.6). Statistically significant differences were found between the pre and postoperative MOXFQ. The postoperative MOXFQ score demonstrated a poorer result for two patients, no change for two patients and improvement in 20 patients, with four of these patients recording the lowest possible score. There was a 29.5 point improvement in mean metric MOXFQ Index score. Seventy-nine percent (n = 19) of patients were satisfied or very satisfied with the operated foot. The average recoil of the metatarsal heads following DMMO was M2 4.01 mm, M3 4.55 mm, M4 4.16 mm. There was one delayed union and no non-unions. Further reported complications were a gastric bleed, pulmonary embolism (VTE), and one intra operative broken burr.

CONCLUSION

Our study demonstrates a clinically important and statistically significant improvement in patient reported outcomes following DMMO, with 79% of patients satisfied or very satisfied with this procedure. The average recoil of the metatarsal heads following DMMO was M2 4.01 mm, M3 4.55 mm, M4 4.16 mm with one delayed union and no non-unions.

Distal Minimally Invasive Metatarsal Osteotomy ("DMMO" Procedure)

The use of a Shannon burr facilitates an osteotomy of the lesser metatarsals without requiring an open approach to the metatarsal. The end result that is aimed for is the same as for open surgery and therefore care needs to be taken to perform the bone cut in the appropriate manner. A description is provided of the surgical technique for distal minimally invasive osteotomy and its newer modifications-the distal intracapsular minimally invasive osteotomy and the distal oblique metatarsal osteotomy.

Resection Arthroplasty: Current Indications and Tips

Resection arthroplasty for metatarsalgia is a selective procedure primarily indicated for patients with rheumatoid arthritis. These patients present with significant forefoot deformities, poor bone quality, and loss of soft tissue integrity. Resection of the metatarsal heads and correction of lesser toe deformities improve pain and decrease transfer metatarsalgia. Patients with concurrent hallux valgus may benefit from a lapidus procedure or hallux metatarsophalangeal fusion in an effort to improve outcomes and decrease incidence of recurrent hallux valgus. In rare cases, diabetics with neuropathy may require resection arthroplasty in the setting of forefoot deformities recalcitrant to other modalities.

Brachymetatarsia: One-stage Versus Two-Stage Procedures

Brachymetatarsia is a rare deformity with controversial clinical presentation. Multiple acute and gradual lengthening surgical techniques have been described for correction of this type of foot deformity. All techniques try to create a better appearance, facilitate shoeing, or solve possible transfer metatarsalgia. Either acute lengthening (1-stage procedure) or gradual lengthening (2 stages) is selected based on the patient's deformities, concerns, and clinical needs.

Mechanical Basis of Metatarsalgia

The 3-rocker mechanism of gait provides a framework to understand why patients have mechanical metatarsal pain and to differentiate between the various types of metatarsalgia. Clinical examination of the patient together with radiological findings allows identification of the type of metatarsalgia and the pathomechanics involved, and the planning of surgical treatment. Second-rocker/nonpropulsive metatarsalgia is related with an abnormal inclination of a metatarsal in the sagittal plane, either anatomic or functional (equinism). Third-rocker/propulsive metatarsalgia is related to an abnormal length of a certain metatarsal with respect to the neighboring metatarsals in the transverse plane.

Metatarsalgia: Assessment Algorithm and Decision Making

Historically, metatarsalgia was approached as a forefoot condition, most often associated with hallux valgus. Consequently, surgical treatments were limited to that anatomic zone, disregarding more proximal structures. In order to assess this entity properly, it is necessary to consider anatomic and biomechanical factors, as well as general and local conditions of the affected patients. A thorough understanding of the multiple potential causal factors is essential to ensure selection of the optimal treatment.

Scientific Evidence in the Treatment of Metatarsalgia

Metatarsalgia is a common foot disease with a multitude of causes. Proper identification of underlying diseases is mandatory to formulate an adequate treatment. Multiple surgical solutions are available to treat metatarsalgia. Only limited scientific evidence is available in the literature. However, most of the techniques used in the treatment of metatarsalgia seem to be reasonable with acceptable results.

Metatarsalgia in Metatarsus Adductus Patients: A Rational Approach

Metatarsus adductus (MA) is a congenital condition resulting in adduction of the forefoot at the tarsometatarsal joint, medial metatarsal deviation, supination of the hindfoot through the subtalar joint, and plantarflexed first ray. The exact underlying pathophysiology remains elusive. There is increasing evidence highlighting the importance of recognizing MA as an associated deformity that complicates management of hallux valgus (HV). Unfortunately, metatarsalgia and lesser toe pathology is also common in this population. We present a review regarding the epidemiology, pathomechanics, and a comprehensive surgical treatment algorithm to optimize the management of patients with MA, HV, lesser toe deformity, and metatarsalgia.

The Role of First Ray Insufficiency in the Development of Metatarsalgia

Two theories exist in the development of central or transfer metatarsalgia. First, as the severity of hallux valgus increases, there is mechanical overload of the second metatarsal. Second, increased relative lesser metatarsal length is thought to contribute to metatarsalgia. It is imperative, in the treatment of first ray disorders (hallux valgus or hallux rigidus), to not overshorten the first ray when addressing the first ray pathologic condition. Treatment of metatarsalgia in the setting of failed hallux valgus correction can be treated with both conservative and surgical options.

Evolution of the Weil Osteotomy: The Triple Osteotomy

Weil osteotomy (WO) is the most common technique worldwide for the treatment of mechanical metatarsalgia. The main indication for WO is propulsive/third rocker metatarsalgia that is in relation with an abnormal length of a certain metatarsal with respect to the neighboring metatarsals in the frontal plane. Most clinical studies have showed good to excellent results after WO. However, complications such as floating toes led to evolution of WO and the development of the triple-cut WO that allows for shortening coaxial to the shaft without plantar translation of metatarsal head. Other variations of WO may treat other forefoot disorders.

Gastrocnemius Recession in the Setting of Metatarsalgia: The Baumann Procedure

A fundamental etiologic component of metatarsalgia is the repetitive loading of a locally concentrated force in the forefoot during gait. In the setting of an isolated gastrocnemius contracture, weight-bearing pressure is shifted toward the forefoot. If metatarsalgia is considered an entity more than a symptom, evaluation of gastrocnemius contracture must be a part of the physical examination, and gastrocnemius recession via the Baumann procedure alone, or in combination with other procedures, considered as an alternative treatment in an attempt to restore normal foot biomechanics.

Forefoot Pain in the Lesser Toes: Anatomical Considerations and Magnetic Resonance Imaging Findings

Various conditions may result in forefoot pain. Magnetic resonance (MR) imaging allows accurate assessment of many of these conditions. We provide an overview of forefoot disorders divided into bones, capsule and plantar plate, musculotendinous structures, neurovascular structures, and subcutaneous tissue. We review normal anatomical features as well as MR imaging findings of common disorders.

Clinical effectiveness and safety of Weil's osteotomy and distal metatarsal mini-invasive osteotomy (DMMO) in the treatment of metatarsalgia: A systematic review

BACKGROUND

Weil's osteotomy (WO) is the most applied surgical treatment for metatarsalgia, a persistent pain in the lesser metatarsals' heads. We aim to review its effectiveness and safety compared to the percutaneous technique known as distal metatarsal mini-invasive osteotomy (DMMO).

METHODS

Systematic review in Medline, Pubmed, Embase, Cinahl and Cochrane Library. We included studies that directly compared WO and DMMO for the treatment of primary metatarsalgia. Data on pain, function, complications and patients' satisfaction were extracted and narratively synthesized.

RESULTS

Four retrospective studies were identified. There were no significant differences in clinical effectiveness or patients' satisfaction. Time to bone healing was significantly longer for DMMO, whereas WO showed more wound problems and metatarsophalangeal stiffness. Other complications were infrequent in the two procedures.

CONCLUSION

Evidence on the direct comparison of WO and DMMO is scarce and of low quality. Randomized studies are needed in order to control for potential confounders.