Estimation of sex using dimensions around the metatarsal diaphyseal nutrient foramen: Application of discriminant function analysis and logistic regression models

Sex estimation equations are population-specific, and a wider use of multiple bones to generate equations will increase the accuracy of sex estimation in forensic settings. The metatarsal bones have been used previously, however the dimensions around the diaphyseal nutrient foramen have not been utilised in sex estimation. The current study aimed to determine the utility of the dimensions around the nutrient foramen of metatarsal bones in estimating sex in the South Africans of European descent (SAED). Five measurements around the nutrient foramen were taken from a total of 876 metatarsal bones (first to fifth) from 186 individual skeletons (99 males, 87 females) obtained from the Raymond A. Dart Modern Skeletal Collection. Measurements subjected to direct and stepwise discriminant function (DFA) and logistic regression (LRA) analyses included total length, distance from proximal end to nutrient foramen, circumference, and mediolateral and dorsoplantar diameters at the level of the nutrient foramen. The original classification accuracies for multivariable functions of the stepwise and direct DFA ranged from 83.1-88.3% to 85.5-88.3%, respectively. The original classification accuracies for multivariable functions of the stepwise and direct LRA ranged from 83.3%-88.7% to 86.2%-88.3%, respectively. The cross-validation classifications showed a drop of 0-2.4% for DFA and 0.2-1.1% for LRA. The width measurements were better predictors of sex than length. The dimensions around the metatarsal bone nutrient foramen exhibit sexual dimorphism in the SAED. The generated DFA and LRA functions produced high average classification accuracies which are useful in sex estimation during forensic human identification.

Metatarsal sliding osteotomy is effective without altering plantar pressure in Morton's neuroma: Retrospective case series

BACKGROUND

Various operative methods for the treatment of Morton's neuroma have been discussed, and osteotomy of the metatarsal bone has been reported recently. However, there has been no report of pedobarographic changes after metatarsal osteotomy. Pedobarographic changes of other metatarsal area after the surgery may cause transfer metatarsalgia, and thorough analysis of the pedobarographic data should be performed peri-operatively. The purpose of this study is to investigate the post-operative pedobarographic changes of sliding osteotomy of the 3rd metatarsal bone for treating Morton's neuroma.

METHODS

Forty patients (45 feet) who underwent metatarsal sliding osteotomy of the 3rd metatarsal bone for treating Morton's neuroma from November 2013 to December 2021 were retrospectively reviewed. Proximal sliding osteotomy was performed at the proximal 3rd metatarsal bone through dorsal approach. Clinical outcomes were evaluated with American Orthopaedic Foot and Ankle Society Lesser Metatarsophalangeal Interphalangeal Scale (AOFAS LMIS), Foot Function Index (FFI), and Visual Analogue Scale (VAS). Plain radiograph and pedobarogram were performed to evaluate the radiologic and pedobarographic outcomes.

RESULTS

AOFAS score was improved from 52.8 ± 9.0 (18-62) to 88.8 ± 9.8 (78-100) and FFI was improved from 61.8 ± 4.9 (50-70) to 32.2 ± 5.1 (23-42) on average. The 3rd metatarsal bone was shortened by 3.1 ± 0.8 mm and dorsally shifted by 1.5 ± 0.4 mm after the surgery. Plantar intermetatarsal distances between 2nd and 3rd and 3rd and 4th metatarsal heads were significantly increased post-operatively. Average forefoot pressure and maximum pressure of the 2nd to 4th metatarsal head were not significantly changed between pre-operatively and post-operatively.

CONCLUSION

Proximal metatarsal sliding osteotomy of the 3rd metatarsal bone shows a satisfactory result in both clinical and pedobarographical evaluations. It could be an effective treatment of permanent indirect decompression of Morton's neuroma with avoiding recurred neuroma, adhesion of tissue, paresthesia, and transfer metatarsalgia.

[Stress fractures in the military context]

BACKGROUND

Soldiers, especially as recruits, are exposed to significantly elevated stress patterns of the foot due to occupation-related marching and excessive running. This can lead to military-specific stress fractures of the metatarsals, i.e., marching fractures. The treatment and prevention of stress fractures are of particular importance in the military context due to the impact on operational capability and treatment costs. A uniform classification of these fractures does not yet exist.

OBJECTIVE

Review of stress fractures in the military setting with presentation of the incidence, risk factors, classification, treatment and prevention possibilities.

MATERIAL AND METHODS

A PubMed®-based review of the current literature on stress fractures in the military context was conducted and the results were discussed with a focus on specific military medical treatment options.

RESULTS

There are several possibilities to classify stress fractures, the most well-known being a 4-level magnetic resonance imaging (MRI)-based classification. Prevention and treatment possibilities are multifaceted but so far insufficiently validated.

CONCLUSION

Military-specific stress fractures should be grouped according to a 4-level and MRI-based classification. The treatment options include both conservative and surgical measures and should be implemented taking the patient's individual requirements into account. Preventive measures play a key role in the military context. They include the adaptation of screening tools, training and equipment and require continuous evaluation and development.

Topographical anatomy and clinical implications of the metatarsal diaphyseal nutrient foramina across South African populations

PURPOSE

Metatarsal fractures often occur around the diaphyseal nutrient foramina (NF) which vary in topography depending on population affinity. Topographical and morphometrical knowledge of the NF is crucial in understanding fracture development and fracture site healing patterns. The current study aimed to describe the topography and the morphometry of the metatarsal diaphyseal NF in South African Africans (SAA), South Africans of European descent (SAED) and South Africans of Mixed Ancestry (SAMA).

METHODS

The study examined 4284 dry cadaveric metatarsals from both sexes and sides of these populations for NF topography and morphometry, including the presence, number, location, position, size and direction of the NF on the metatarsal bones.

RESULTS

The NF was present in 99.4% of the metatarsals. Most (84.5%) metatarsals examined had a single NF. Most (97.4%) NF were located in the middle third of the metatarsal bones. The median foramina index (FI) of the second metatarsal exhibited population affinity and significant differences were found both on the left second metatarsal (P = 0.043), and the right second metatarsal (P = 0.046). The position of NF was predominantly lateral on the first (92.4%), second (64.9%) and third (59.1%) metatarsals, whilst the position was predominantly medial on the fifth (65.1%) metatarsals. The NF positions on the fourth metatarsals showed the greatest population variability. The first metatarsals had primarily dominant-sized and distally directed NF whilst the second through fifth had primarily secondary-sized and proximally directed NF.

CONCLUSION

The topographical anatomy of the metatarsal diaphyseal NF appears similar across the South African populations. Metatarsal bones are highly vascularized bones presenting with multiple nutrient foramina.

[Rotating Scarf osteotomy in treating hallux valgus combined with the first metatarsal rotation]

OBJECTIVE

To explore clinical effect of rotational Scarf osteotomy in treating hallux valgus (HV) with rotation of the first metatarsal bone.

METHODS

From January 2018 to October 2019, 35 patients (40 feet) with HV and rotation deformity of the first metatarsal were treated with rotational Scarf osteotomy, including 5 males and 30 females;aged from 25 to 76 years old with an average of (40.32±5.43) years old. Hallux valgus angle(HVA), intermetatarsal angle (IMA), distal metatarsal articular angle (DMAA), the first metatarsal length (FML) were observed and compared, American Orthopedic Foot and Ankle Society(AOFAS) of hallux metatarsophalangeal interphalangeal joint score and visual analogue scale (VAS) were used to evaluate functional evaluation.

RESULTS

Thirty-five patients(40 feet) were followed up from 12 to 36 months with an average of (14.35±3.62) months. HVA, IMA and DMAA were corrected from (36.32±4.51) °, (14.21±3.22) ° and (28.35±4.32) ° before operation to (14.32±5.71) °, (5.83±3.97) ° and (7.32±2.14) ° after operation respectively (P<0.05). There was no satistical difference in FML before and after operation (P>0.05). AOFAS score and VAS improved from (57.00±4.31) and (6.00±1.21) before operation to (90.31±3.28) and (1.42±0.83) after operation, respectively, and had significant difference(P<0.05);according to AOFAS score, 23 feet got excellent results, 15 feet good and 2 feet fair.

CONCLUSION

Rotational Scarf osteotomy with strong correction and high dimension could effectively correct HV combined with rotation deformity of the first metatarsal bone, improve function of the forefoot, and obtain good clinical results.

[Clinical analysis of external micro-locking plate in the treatment of fifth metatarsal comminuted fractures]

OBJECTIVE

To explore the clinical efficacy of external micro-locking plate combined with closed reduction in the treatment of fifth metatarsal comminuted fracture with severe soft tissue injury.

METHODS

From January 2018 to December 2019, 13 patients received micro-locking plate combined with closed reduction treatment due to the fifth metatarsal comminuted fracture with severe soft tissue injury. There were 11 males and 2 females patients, ranging in age from 21 to 69 years. According to the fracture AO fracture classification, 9 cases belonged to type 87(S)-C2.2 and 4 cases belonged to type 87(S)-C2.1. The fifth metatarsal cuneiform articular surface was not involved, and all of them were comminuted fractures of the fifth metatarsal shaft. All soft tissues were damaged to varying degrees. Three patients got small defect of skin and soft tissue, and they were treated with debridement and suture after one-stage emergency surgery. The fracture healing and complications were observed, and the clinical efficacy was evaluated according to the midfoot function score of American Orthopaedic Foot & Ankle Society (AOFAS) at the latest follow-up.

RESULTS

All patients were followed up, and the duration ranged from 3 to 12 months. One patient had delayed union. One patient had local skin necrosis and was treated with second-stage skin grafting to repair the wound surface. No external screw breakage or infection was reported, the skin soft tissue healed satisfactorily and reached bony union, with the union time ranging from 8 to 19 weeks. The postoperative functional recovery was rated according to the midfoot score of AOFAS, the score ranged from 49 to 98, and 7 patients got an excellent result, 4 good, 1 fair and 1 poor.

CONCLUSION

The external micro-locking plate combined with closed reduction in the treatment of fifth metatarsal comminuted fracture with severe soft tissue injury has the advantages of simple operation, good stability and low infection rate, which is helpful to the repair of soft issue injury, and the fixation can be removed early in outpatient clinic. To sum up, this surgical procedure is suitable for patients with severe soft tissue injury and comminuted fracture to avoid periosteum stripping. The space occupying is smaller than the micro-external fixator, which is convenient for patients with early functional exercise.

Association between Bone Mineral Density and Fracture Characteristics in the 5th Metatarsal Bone Base Fracture in Elderly for Prediction of Osteoporotic Fracture

Background

This study aimed to analyze the correlation between bone mineral density (BMD) and the type of 5th metatarsal fracture, as well as to demonstrate whether there is a difference in radiological findings (heel alignment angle [HAA], heel moment arm [HMA], and metatarsus angle) between fracture types.

Methods

A total of 87 patients were enrolled in the study and allocated into 3 groups: the Zone 1 group (N=36), the Zone 2 group (N=33), and the Zone 3 group (N=18). The participants’ demographic data, T-scores, existing fracture or osteoporosis medications, and radiologic parameters including HAA, HMA, and metatarsus adductus angle were analyzed and compared.

Results

There was a significant difference between the mean age of the participants, with the highest age in the Zone 1 group and the lowest in the Zone 3 group. Regarding the history of concurrent fracture or osteoporosis medications, there was no significant difference between the 3 groups. Similarly, no significant difference was observed between the 3 groups about the BMD values. In contrast, the HAA was statistically significant in all groups with a positive correlation of −8.9 in the Zone 1 group, a negative correlation of 3.55 in the Zone 2 group, and an inverse relationship of 6.1 in the Zone 3 group. The metatarsus adductus angle was significantly higher in the Zone 3 group than the Zone 1 and Zone 2 groups.

Conclusions

The location of a 5th metatarsal bone fracture is not significantly associated with BMD. However, mechanical influences, such as hindfoot varus or forefoot adductus, have a significant correlation with fracture types.

[Treatment of plantar, neuropathic and metatarsal ulcers by minimally invasive metatarsal osteotomy]

BACKGROUND

The chronic-mechanical plantar ulcer in diabetic-neuropathic foot syndrome is the starting point for severe infections of the foot and amputations. Frequent predilection sites are the metatarsal heads (MTH); in the context of neuropathy increased plantar peak pressure occurs and leads to an ulcer.

GOAL

In this paper, we will examine whether minimally invasive pressure-reducing osteotomies, such as distal, minimally invasive metatarsal osteotomy (DMMO), can lead to the healing of metatarsal ulcers. Furthermore, the frequency of postoperative complications will be analyzed.

METHOD

In a prospective study, n = 26 consecutive patients with plantar grade IA, IIA, and IIIA ulcers according to Wagner/Armstrong were included in the study under MTH 2, 3, 4 and 5 and with an unsuccessful conservative therapy >6 months. All patients received a DMMO of MT 2, 3, and 4, unless the ulcer was under MTH 5, then isolated DMMO MT 5 was performed. Clinical radiological check-ups took place over a follow-up interval of 26 ± 18 months (8-43 months).

RESULTS

In all patients, the plantar ulcera healed after 5 ± 1 week, the recurrence rate was 8% and 3 patients had a transfer ulcer. Complications such as infection, pseudarthrosis or neuroosteoarthropathy did not occur.

CONCLUSION

DMMO is an effective method for the treatment of recalcitrant ulcers under the metatarsal heads. The rate of a long-term cure is high; the complication rate is low; in ulcers under MTH 5, the DMMO should possibly be extended to the other metatarsal heads to reduce the risk of a transfer ulcer.

Modified Proximal Scarf Osteotomy for Hallux Valgus

Background

We developed a modified proximal scarf osteotomy technique for moderate to severe hallux valgus in an attempt to obtain better correction of the deformity. In addition, we compared the clinical and radiographic results of this modified technique with those of the classic scarf osteotomy reported in other studies.

Methods

Between December 2004 and July 2009, 44 cases of modified proximal scarf osteotomy was performed in 35 patients with moderate hallux valgus. The American Orthopedic Foot and Ankle Society (AOFAS) score, visual analogue scale (VAS) score, range of motion of the first metatarsophalangeal joint, and radiographic results were evaluated.

Results

The mean hallux valgus angle and the mean first intermetatarsal angle improved from an average of 32.2° and 14.3°, respectively, to an average of 12.5° and 8.6°, respectively. The distal metatarsal articular angle improved from an average of 18.7° to 12.4°. The preoperative mean AOFAS and VAS scores were 47 points and 7 points, respectively, which improved to 86 points and 1 point, respectively, at the final follow-up. Limited range of motion occurred in two cases postoperatively. The height of the first metatarsal-cuneiform joint, which was an average of 15.9 mm preoperatively, did not change. The first metatarsal-talus angle increased from an average of 4.1° to 7.1°.

Conclusions

The modified proximal scarf osteotomy for the treatment of moderate hallux valgus showed similar results with the classic scarf osteotomy with regard to changes in the first intermetatarsal angle and postoperative satisfaction. Therefore, we suggest the modified proximal scarf osteotomy be considered as well as other proximal osteotomy in the treatment of moderate to severe hallux valgus.

[Forefoot relief with shoe inserts : Effects of different construction strategies]

BACKGROUND

Shoe inserts and shoe modifications are used to reduce plantar peak pressure. The effects of different shoe inserts and shoe construction strategies for relief of the forefoot have not yet been sufficiently evaluated.

PURPOSE

The aim of this study was to analyze the effects of shoe inserts and shoe construction strategies (e.g. metatarsal pad, forefoot cushioning and control) and shoe modifications (e.g. flexible or stiff) on the peak plantar pressure in the forefoot region.

MATERIAL AND METHODS

In this study 15 healthy subjects were recruited. Plantar pressure distribution was measured using an in-shoe system during walking (3.5km∙h^-1) on a treadmill and the average plantar peak pressure (kPa) in the forefoot was calculated. The statistics for testing the hypothesis were carried out using 2‑factorial ANOVA with repeat measurements (factors: shoe, insert; α = 0.05).

RESULTS

The metatarsal pad and forefoot cushioning led to a reduction of peak pressure, which was statistically significant compared to the control condition (p = 0.009). No differences were observed between both shoe inserts (p > 0.05). A comparison between stiff and flexible shoes revealed a statistically significant pressure reduction in favor of stiff shoes (p = 0.0001). The metatarsal pad led to a peak pressure increase in the midfoot of 12% and by 21% compared to control and forefoot cushioning, respectively.

DISCUSSION

A peak pressure reduction in the forefoot can be achieved with a metatarsal pad or with cushioning; however, the metatarsal pad resulted in a subsequent increase in midfoot pressure. Moreover, shoe construction is crucial because a stiff shoe contributes to a better peak pressure reduction compared to a flexible shoe. Prospective clinical studies should be carried out to prove whether this results in beneficial effects for patients with metatarsalgia.

[SCARF osteotomy]

Hallux valgus is one of the most common deformities of the lower extremity. Multiple etiologies have been discussed, and various techniques have been described. The SCARF osteotomy is indicated for moderate to severe hallux valgus deformities. The technique historically used by carpenters allows immediate postoperative weight bearing and also entails the possibility to correct the distal metatarsal articular angle by rotation of the osteotomy. The SCARF osteotomy has also been successfully used in revision surgeries.

[Distal osteotomy for the treatment of hallux valgus (Chevron osteotomy)]

Distal osteotomies, like the Chevron osteotomy, is indicated for mild to moderate hallux valgus deformities. Splayfoot, painful pseudoexostosis, and transfer metatasalgia are observed in the clinical examination. Radiographic examination should be done with weight bearing in two planes. Preoperatively the intermetatarsal (IM), hallux valgus, and distal metatarsal articular (DMAA) angles should be measured. The operative technique is based on soft tissue and bony correction. Modifications of the osteotomy allow a shortening, lengthening, or neutral correction of the first metatarsal. With a modified Chevron osteotomy, an increased DMAA can be also corrected.

The Accuracy of Sex Estimation on Metatarsal Bones in a Northeastern Thai Population

BACKGROUND

This study was carried out to evaluate the accuracy of sex estimation by discriminant analysis and stepwise discriminant analysis equations generated from metatarsal bones in a Thai population.

MATERIAL AND METHODS

The testing samples utilized in this study consisted of 50 skeletons (25 males and 25 females) obtained from the Khon Kaen University Skeletal Collection, Department of Anatomy, Faculty of Medicine, Khon Kaen University. Seven measurements of metatarsal bones were measured in centimeters, using either a mini-osteometric board (MOB) or a sliding caliper. The values measured from the Khon Kaen Skeletal Collection were used to determine the accuracy and applicability of sex determination, as predicted by Y1-Y6 equations which were generated from a Chiang Mai Skeletal Collection.

RESULTS

The percentage of sex determination accuracies predicted from the Y1-Y6 equations demonstrated accuracy rates of 80-95.6.

CONCLUSIONS

The Chiang Mai sex determination equations, generated from metatarsal bones by discriminant analysis (Y1-Y3) and stepwise discriminant analysis (Y4-Y6), demonstrated high accuracy rates of prediction, suggesting that these equations may be useful for sex determination within the Thai population.

Study of the metatarsal formula in patient with primary metatarsalgia

Objectives

The aims of this study were (i) to ascertain the prevalence of different types of metatarsal formula among patients with primary metatarsalgia; (ii) to compare the variable of “shortening of the first metatarsal in relation to the second” (I/II) between the metatarsalgia and control groups; and (iii) to analyze the intra and interobserver concordance by means of Morton's transverse line method and Hardy and Clapham's arc method.

Methods

A cross-sectional observational study was conducted on 56 patients by means of radiographs on their 112 ft, of which 56 were in the metatarsalgia group and 56 in the control group. The evaluations were done between December 2012 and June 2013. The measurements were made by three third-year orthopedics residents with prior training in the methods used, and a template was used.

Results

There was no concordance between the two methods, as shown by Bland–Altman plots, although the intraclass correlation coefficients showed that the intra and interobserver reproducibility was high using the transverse line method (0.78 and 0.85) and moderate using the arc method (0.73 and 0.60). Comparison between the groups showed that there was a statistical difference (p ≤ 0.05) such that there was greater shortening of the first metatarsal (3.39 mm) in the control group than in the metatarsalgia group (2.14 mm). In the patients with primary metatarsalgia, the index minus metatarsal formula was more prevalent according to the transverse line method (62.5%) and the zero plus type according to the arc method (71.4%).

Conclusion

In the present study, it was observed that the metatarsal formula prevalences depended on the measurement method. In both groups, shortening of the first metatarsal predominated. There was no intra or interobserver concordance in either of the two proposed methods.

Turco's injury: diagnosis and treatment

The aim of this study was to alert doctors to the existence of Turco's injury and discus the existing treatments that have been described in the worldwide literature. A bibliographic survey of Lisfranc's injury and Turco's injury covering from 1985 to 2013 was conducted in the SciELO and PubMed databases. Among the 193 articles, those relating to bone-ligament injuries of the Lisfranc joint and high-energy trauma were excluded, as were the case reports. The patients selected were professional or amateur athletes who solely presented a ligament injury to the Lisfranc joint (Turco's injury), which was diagnosed from the history, physical examination, radiographs and magnetic resonance images. Non-athletic patients and those with associated bone injuries were excluded (10). According to the injury classification, the patients were treated by means of either an open or a closed procedure and then a standard rehabilitation protocol. Out of the 10 patients, five underwent conservative treatment and five underwent surgical treatment using different techniques and synthesis materials. We obtained two poor results, one satisfactory, five good and two excellent. We conclude that the correct diagnosis has a direct influence on the treatment and on the final result obtained, and that lack of knowledge of this injury is the main factor responsible for underdiagnosing Turco's injury. There is a need for randomized prospective studies comparing the types of synthesis and evolution of treated cases, in order to define the best treatment for this injury.

Intramedullary screw fixation of proximal fifth metatarsal fractures in athletes

Objective

The purpose of this study was to review the short- and long-term clinical and radiological results of intramedullary compression screw fixation of proximal fifth metatarsal fractures in athletes.

Methods

Eleven male and six female active patients with fifth metatarsal zone II and zone III fractures fixed with a 4.5-mm cannulated compression screw were evaluated by chart review, review of radiographs, and clinical evaluation. Fifteen of the patients were high-level athletes (soccer: n=11; basketball: n=1; track and field: n=3) and two were recreational-level athletes. Mean follow-up from surgery to evaluation was 54 (38-70) months.

Results

Mean time to healing as shown on radiographs and mean time to return to full activity after surgery were 7.3 and 7.5 weeks, respectively. All patients were able to return to their previous levels of activity. There were no reports of union delay, nonunion or refracture to date.

Conclusion

In our patients, cannulated screw fixation of proximal fifth metatarsal fractures was a reliable procedure with low morbidity associated that provided athletes a quick return to activity. Level of Evidence I, Case Series.

OSTEOTOMY OF THE FIRST METATARSAL BASE ON THE TREATMENT OF MODERATE TO SEVERE HALLUX VALGUS RESULTS AFTER MEAN FOLLOW-UP TIME OF EIGHT YEARS

Objective: To assess the result of the treatment of moderate to severe hallux valgus with osteotomy of the first metatarsal base associated to distal release of soft parts and medial capsuloplasty. Methods: 13 patients were assessed (15 feet) submitted to surgical treatment of hallux valgus moderate to severe. The mean follow-up time was 102 months; there were 12 female and 1 male patients, with mean age at the time of surgery of 49 years. The patients enrolled were interviewed according to the questionnaire developed by our service, clinically examined according to the AOFAS scale and submitted to X-ray tests for comparing the results with baseline images. Results: The mean score of the AOFAS scale obtained at the final assessment was 82 points. Nine of the 15 feet (60%) showed some late complications, with four (27%) varus deformities, three (20%) recurrences; two patients (13%) presenting with pain complaints with no associated deformity. In the hallux metatarsophalangeal joint, movement loss was 41° (57%); dorsiflexion movement was mostly affected, with a mean loss of 37° (60%). The range of motion on the contralateral intact side served as control group. Arthrosis progression was seen on the final X-ray evaluation. In all cases, shortening and lifting of the first metatarsal were noticed; however, we couldn't correlate the shortening and lifting with metatarsalgia, plant callosity or lower scoring on the AOFAS scale at the final evaluation. Conclusions: The osteotomy technique by the basis and with distal realignment of soft parts employed in the treatment of moderate to severe hallux valgus showed a high rate of late complications. Due to the high number of complications, we believe that adopting this technique for correcting hallux valgus deformities should be carefully considered.