A new classification for Freiberg's disease

INTRODUCTION

Freiberg's osteochondrosis is an uncommon cause of foot pain. Following a national survey circulated by the British Foot and Ankle Society it was found that no classification is used to guide surgical treatment. This study aimed to create a simple, reproducible CT based classification to preoperatively plan whether an osteotomy is required.

METHODS

A retrospective review of 24 CT scans of new Freiberg's diseasediagnoses over a 10 year period was conducted. These images were assigned a study number and anonymised. The scans were then reviewed in their entirety by three independent specialists who determined whether an osteotomy would be of benefit. The sagittal CT slice that displayed the widest portion of proximal articular margin of the proximal phalanx was identified and divided the articular surface into 2 zones - plantar and dorsal and this formed the basis for our classification. These sagittal slices were then reviewed independently by two surgeons to determine if patients had disease in one or both zones and re-reviewed two weeks later to assess intra-observer reliability.

RESULTS

All 24 cases involved the second metatarsal. From reviewing the sagittal CT slices, it was felt that 18 patients were suitable for osteotomy and 6 were suitable for debridement +/- arthroplasty alone. The current classification demonstrated that 18 patients had disease confined to zone 1 only and the remaining patients had disease in both zones. Inter-observer reliability assessment had 95.8% agreement (Krippendorff's Alpha 0.897). Intra-observer reliability was 100%. Correlation of those observed to have isolated zone 1 disease and suitability for osteotomy was absolute (Pearson r = 1).

CONCLUSION

Dividing the metatarsal head into two zones on the widest sagittal slice of the CT scan offers an easy reproducible way to preoperatively plan surgical treatment for Freiberg's osteochondrosis. Patients with isolated zone 1 disease should be suitable for an osteotomy.

Overview of Metatarsalgia

Metatarsalgia can be viewed as more of a symptom rather than a distinct diagnosis. Timing of forefoot pain during the gait cycle and evaluation of whether the pain is from anatomic abnormalities, indirect overloading, or iatrogenic causes can suggest a specific metatarsalgia etiology. A thorough physical examination of the lower extremity, especially evaluation of the plantar foot, and weight-bearing radiographs are critical for diagnosis and treatment. Nonoperative treatment consists of physical therapy, orthotics, shoe wear modification, and injections. If conservative treatment fails, surgical options may be considered. [Orthopedics. 2019; 42(1):e138-e143.].

Return to sporting activity after osteochondral autograft transplantation for Freiberg disease in young athletes

INTRODUCTION

Freiberg disease is defined as osteochondrosis of the metatarsal head and typically occurs in adolescents with sporting activity. This study aimed to evaluate the sporting activity of young athletes after osteochondral autograft transplantation (OAT) for Freiberg disease.

MATERIALS AND METHODS

OAT for Freiberg disease was conducted in 12 consecutive patients between August 2008 and November 2014. The present study evaluated 10 of these patients who both undertook sporting activity preoperatively and were teenagers at the time of surgery. Clinical evaluations were performed based on the Japanese Society for Surgery of the Foot lesser metatarsophalangeal-interphalangeal scale (JSSF scale) and range of motion (ROM) of the operated metatarsophalangeal joint preoperatively and at the final follow-up (mean 24.6 months). Whether patients were able to return to sporting activity and time until return to sporting activity were evaluated, including the Halasi score to reflect the level of sporting activity. Regarding symptoms at the donor knee, the Lysholm knee scale score was evaluated at the final follow-up.

RESULTS

The mean JSSF scale showed a significant improvement at the final follow-up (p < 0.01). The mean ROM in extension and flexion improved at the final follow-up (p < 0.01, and p < 0.05, respectively). All patients were able to return to sporting activity at a mean time of 3.5 months postoperatively and the Halasi score showed no significant change. The mean Lysholm knee scale score was 97.9 (range 89-100) points at the final follow-up.

CONCLUSIONS

All young athletes who underwent OAT for Freiberg disease achieved early return to almost equal sporting activity postoperatively and exhibited a significant improvement of the ROM of the metatarsophalangeal joint with almost no knee pain.

Surgical Management of Freiberg's Infraction: A Systematic Review

Avascular necrosis of the second metatarsal head was first described by Freiberg in 1913. Conservative treatment includes nonsteroidal anti-inflammatory medication, reduced activity, padding, orthotics, and immobilization. Should conservative treatment fail, a wide variety of surgical procedures exist; however, the optimal procedure is unknown. This systematic review was undertaken to determine which surgical procedure allows for the best resolution of symptoms and return to activity. Included studies were restricted to articles published in English language peer-reviewed journals that consecutively enrolled patients of all ages, with Freiberg's infraction of any stage, who underwent operative treatment, and had a mean follow-up of greater than or equal to 12 months duration. Eighty-five publications were identified, of which 38 (44.7%) met all the inclusion criteria. Surgical techniques and outcomes were grouped into joint sparing and joint destructive procedures. A total of 70 joint destructive procedures were performed with a combined mean follow-up time of 15.0 months. A greater than 70% resolution of pain and full return to activity was reported. A total of 257 joint sparing procedures were performed with a combined mean follow-up of 30.4 months. A greater than 90% resolution of pain and full return to activity was reported. Results of this systematic review reveal that the results of joint sparing procedures are reported more often and appear to have a better prognosis for symptom resolution and return to activity. Smillie stage was not consistently reported, making it difficult to determine its effect on procedure selection.

LEVEL OF EVIDENCE

Therapeutic, Level IV: Systematic review of Level IV studies.

Co-segregation of Freiberg's infraction with a familial translocation t(5;7)(p13.3;p22.2) ascertained by a child with cri du chat syndrome and brachydactyly type A1B

The identification of chromosomal breakpoints in association with human abnormal phenotypes can enable elucidation of gene function. We report on epiphyseal aseptic necrosis of the lesser head of the second metatarsal bone, known as Freiberg's infraction (FI), in two female carriers of the apparently balanced t(5;7)(p13.3;p22.2) ascertained by a 16-year-old girl with cri-du-chat syndrome and unusual skeletal features in association with an unbalanced translocation der(5) t(5;7)(p13.3;p22.2). Mapping of the chromosome breakpoints using fluorescent in situ hybridization (FISH) narrowed them to the coding sequence of ADAMTS12 on chromosome 5p13.3 and SDK1 on 7p22.2. In addition, several skeletal abnormalities classified as brachydactyly type A1B (BDA1B) were present in the proband and in both carriers of t(5;7)(p13.3;p22.2), suggesting a potential role of ADAMTS12 in the development of the BDA1B observed in this family.

[Second Köhler disease]

Les auteurs rapportent 17 cas de la deuxième maladie de Köhler. Il s'agit de jeunes femmes (13 cas), qui ont consulté pour des douleurs métatarso-phalangiennes unilatérales de type mécanique. La maladie touche la deuxième tête métatarsienne dans 14 cas. Le diagnostic est posé grâce à la radiologie: le stade III est retrouvé dans 11 cas. Nous avons opté pour l'intervention de Gauthier: Ostéotomie de dorsiflexion de la tête métatarsienne par résection cunéiforme à base dorsale de la zone nécrotique. Les suites opératoires sont bonnes et l’évolution est favorable pour nos patients, avec un recul moyen de 3 ans.

A reappraisal of the relationship between metatarsus adductus and hallux valgus

BACKGROUND

A causal link between the metatarsus adductus and hallux valgus is not clear. The aim of this study was to investigate the configurations of the metatarsus adductus deformity by radiological measurements and reappraise the relationship between hallux valgus and metatarsus adductus.

METHODS

The first step was evaluation of the relationship between metatarsus adductus and hallux valgus on 143 dorsoplantar weight-bearing radiographs diagnosed as hallux valgus which was also known as bunions. Measurements including the hallux valgus angle (HVA), the intermetatarsal angle (IMA), the Kilmartin angle (KA), the tibial sesamoid position (TSP), and metatarsus adductus angle were taken. The metatarsus adductus angle is defined by Sgarlato's angle (SMA) and Engel's angle (EMA) respectively.

RESULTS

The metatarsus adductus angle positively correlates with the HVA (r = 0.590, P = 0.000) and KA (r = 0.601, P = 0.000), yet negatively correlates with the grade of TSP, (r = -0.348, P = 0.000). Contradiction of diagnosis existed in 22 (22/100) subjects diagnosed as metatarsus adductus by SMA yet normal by EMA. In this group, the correlation between HVA and metatarsus adductus angle was negative (r = -0.472, P = 0.027).

CONCLUSIONS

EMA and SMA defined metatarsus adductus by different deformity apexes. Metatarsus adductus configurations in that the apex of the deformity lay in either the base of metatarsals or tarsus. They respectively correlate positively or negatively to the HVA.

A simple surgical technique for treatment of Freiberg's disease

BACKGROUND

Of all the osteochondrosis, Freiberg's disease is reported to be the fourth most common, exceeded by Köhler's disease, Panner's disease, and Sever's disease. This disease usually occurs in the 2nd metatarsal head and relatively in the 3rd and 4th metatarsal heads.

OBJECTIVE

The purpose of this study was to evaluate the outcome of debridement, synovectomy, dorsal closing wedge osteotomy and pin fixation for Freiberg's disease treatment.

METHODS

Ten female patients, mean age 18.3 years; (ranged 14-24 years) were treated by the above mentioned technique. The main presenting symptom was pain on walking or sport; affected their daily life and activities and was not improved by non-surgical treatment. The second metatarsal head was affected in all patients. Halve of patients had a history of trauma. According to Smillie's classification, four patients were type V and six patients were type IV. Mean follow-up period was 19.2 months (range 6-36 months).

RESULTS

Were assessed by the Lesser Metatarsophalangeal-Interphalangeal (LMPI)Scale by Kitaoka et al. At the final follow up, scoring was changed from (44-76) with an average 57 to (66-100) with an average 80. There was no case of infection, avascular necrosis, arthritis or pseudoarthrosis.

CONCLUSION

We founded that dorsiflexion osteotomy of the metatarsal head is presented as a logical procedure that is simple, reliable, not destructive, and capable of good results regardless of the stage of the disease.

A case of polydactyly in the hind-limbs of a West African Dwarf goat in South-West Nigeria

This report describes a case of polydactyly in the hind-limb of a West African Dwarf goat kid in South West Africa. Physical examination revealed the presence of four digits in each of the hind limbs. Radiological examination and macerated bones of the animal showed a bifid shape of each metatarsal that was more prominent from the distal half of the diaphysis. This resulted in the presence of four articulating surfaces per limb at the distal extremity. Though this condition is rare in goats, we advise that continuous reporting by researchers can give a better prevalence statistics of these occurrences.

Prevalence of osteochondritis among preparatory and primary school children in an Egyptian governorate

Epiphyseal osteochondritis is a localized disorder in childhood. Vascular insufficiency is thought to be the most significant etiologic factor. This study had been carried on Primary and Preparatory school children in Zagazig City and surrounding villages in Sharkia Governorate, Egypt. Total number of studied children were 16,060, 7,380 males, 8,680 females. The mean age was 11.41 ± 1.99. Our results showed that the prevalence of osteochondritis was 21:10,000. Distribution of Sever's and Osgood-Shlatter diseases were significantly high compared with other osteochondritis. Regarding the sex distribution, osteochondritis was frequent in males. Our results showed that there was history of trauma especially in Sever's and Osgood-Schlatter diseases.

[A boy with a painful foot]

A 4-year-old boy visited the emergency department with a painful foot. We diagnosed osteochondrosis of the tarsal navicular, also known as Köhler's disease. The patient was successfully treated with a plaster bandage for 4 weeks.

Use of internal callus distraction in the treatment of congenital brachymetatarsia

Congenital bilateral brachymetatarsia of the fourth metatarsal bone was treated by osteotomy and bone lengthening using the internal distraction technique. The patient was cosmetically improved. This technique has some advantages over the method of external distraction.

[Correction of acquired metatarsus elevatus and hallux flexus: technique used in nine cases]

Nine cases of acquired metatarus elevatus or horizontalization of the first metatarsal with hallux flexus (dorsal bunion) were treated surgically associating: plantar wedge resection of the base of the first metatarsal or the first cuneiform; distal disinsertion of the long hallux flexor which was then positioned under the base of the first metatarsal and finally fixed on the distal dorsal segment of the metatarsophalangeal capsule; distal disinsertion of the anterior tibial tendon and tenodesis of the posterior tibial tendon. Weight bearing was allowed after pinning for one Month to position the axis of the first ray. Morphological results, recorded at 11 Years follow-up (mean) were satisfactory. There were no recurrent deformations and no residual instability of the first ray. The only observation was a minimal stiffness of the metatarsophalangeal joint with no tendency to degeneration.

[Bone lengthening of congenitally short metacarpus and metatarsus by the callus distraction technique]

OBJECTIVES

We evaluated the results of lengthening of congenitally short metacarpus and metatarsus by the callus distraction technique.

METHODS

We treated congenitally short metacarpus (n=7) and metatarsus (n=4) of five patients (4 females, 1 male; mean age 15 years; range 10 to 21 years) by callotasis. Callus distraction was performed with the use of mini-Orthofix or Ilizarov type semicircular external fixators. The distraction rate was 0.25x2 mm/day for both types. The mean follow-up period was 23 months (range 12 to 33 months).

RESULTS

The mean metacarpal and metatarsal lengthenings were 20 mm (range 15 to 25 mm) and 25 mm (range 20 to 30 mm), respectively. The mean healing index was 1.4 months/cm for metacarpal lengthening, and 1.8 months/cm for metatarsal lengthening. No neurovascular complications were encountered. One patient required autogenous fibular grafting for union. Pin tract infections were found in three patients. The overall complication rate was 36%.

CONCLUSION

Callotasis is an effective and reliable method for lengthening of short metacarpal and metatarsal bones. In addition, it preserves the periosteal bone tissues, which has a favorable effect on the duration of treatment.

Examination of the newborn foot: positional and structural abnormalities

Newborn feet come in a variety of shapes and sizes. The foot is malleable, making it susceptible to compression and deformation from intrauterine positioning. Clinicians frequently question whether variations represent deformations, that is, an alteration in the shape and contour of a normally formed foot, as opposed to a true structural malformation. Distinguishing between a temporary positional deformity and a more serious structural foot malformation is challenging and requires a clear understanding of the anatomy of the foot, its complex embryologic development, and the impact of environmental and intrauterine factors. This installment of Focus on the Physical provides a systematic framework to identify normal, abnormal, and atypical foot deformities in the newborn period. The current theories of pathogenesis are provided, along with a step-by-step approach to the examination of the foot. A series of clinical photographs illustrate talipes equinovarus, metatarsus adductus, talipes calcaneovalgus, and congenital vertical talus. A discussion of the diagnostic studies used to differentiate these abnormalities is provided, along with a brief overview of treatment options. Early recognition and treatment are essential to ensure optimal long-term functional outcomes.

Rare case of a rudimentary medial metatarsal non-ossified structure

A 9-year-old boy presented with a rudimentary medical metatarsal non-ossified structure. We considered his condition to be classified as hypoplastic medial member type in the metatarsal type of medial ray polydactyly. When it was considered as polydactyly, it had the longest delay of ossification among reported cases.

Midline metatarsal dysplasia associated with absent fibula

In 5 patients with congenital deficiency of the fibula, the degree of fibular deficiency ranged from unilaterally short to bilaterally absent. The patients each had at least one missing metatarsal and, in addition, dysplasia of a midline metatarsal. In view of these findings, some missing metatarsals associated with congenital fibular deficiency could be midline metatarsals. The abnormality could represent a deficiency acquired after the development of the embryonic limb bud cartilage models.

Physical mapping of the t(12;22) translocation breakpoints in a family with a complex type of 3/3'/4 synpolydactyly

We previously reported clinical and radiological findings in a Belgian family with a complex type of synpolydactyly associated with metacarpal and metatarsal synostoses, cosegregating with a balanced t(12;22). Recently, expansions of a polyalanine stretch within the first exon of the HOXD13 gene, which resides on chromosome 2q31, have been shown to cause synpolydactyly (SPD). Using exon amplification followed by direct sequencing, we were able to exclude the direct involvement of the HOXD13 gene in this family. As a first step toward the positional cloning of a candidate disease gene on chromosome 12 and/or 22 responsible for the type of complex synpolydactyly observed in this family, we report here the construction of a somatic cell hybrid retaining only the der(22) of the t(12;22)(p11.3;q13.3). STS content mapping and FISH experiments allowed us to position the chromosomal breakpoints between markers D12S1596 and D12S1034 on chromosome 12 and markers N73F4 and D22S158 on chromosome 22.

A syndrome of digital fibromas, facial pigmentary dysplasia, and metacarpal and metatarsal disorganization

We report on a girl with fibrous tumors involving hands and feet associated with unusual brachydactyly and facial abnormalities with pigmentary skin lesions. The multiple, infiltrative fibrous tumors clinically resembled recurring digital fibromata (RDF) of infancy, but eosinophilic cytoplasmic inclusion bodies pathognomonic for RDF were not demonstrated in her tumor cells. Skeletal alterations of the hands and feet comprised brachymesophalangy with cone-shaped epiphyses and variable shortening and deformity of the metacarpals and metatarsals. Facial abnormalities included upward slant of palpebral fissures, primary telecanthus with epicanthal folds, and a depressed nasal tip, along with a small fibrous tumor on the left eyelid. The patient also had patchy, brownish discolorations of the face. The clinical, radiological, and histological constellation in the patient may represent a hitherto undescribed hamartomatous syndrome.

A rare case of complete proximal epiphyses (so-called pseudoepiphyses) of the metacarpal and metatarsal bones in the human

We report a rare case of complete proximal epiphyses (so-called pseudoepiphyses) of metacarpal and metatarsal bones in a human. These phenomena were seen in both the hands and feet of a seven-year-old girl undergoing medical examination for pain in the right foot. During medical treatment, X-ray photographs of the hands and feet were taken. Each metacarpal and metatarsal bone except for the first metacarpal bones had supernumerary epiphyses (complete pseudoepiphyses) at the nonepiphyseal end of these bones. This is a rare case even for an experienced orthopaedic surgeon.

Rotational deformities in the lower extremities

Rotational abnormalities of the lower extremities remain a significant complaint among parents of pediatric patients. Intoeing can result from metatarsus adductus, internal tibial torsion, or femoral anteversion. Rarely is orthopedic treatment necessary. Current recommendations regarding the treatment of intoeing are given.

Evaluation and management of in-toe gait in the neurologically intact child

A review of the nature, cause, natural history, and measurement of torsional problems of the lower extremity has been presented. A focused discussion of the often ignored consequences of residual torsions and the compensations for them when they are present has been included. Finally, current thought on management principles and techniques has been reviewed.

Congenital metatarsus adductus in early human fetal development: a histologic study

Two feet with congenital metatarsus adductus from fetuses at early development (16 and 19 weeks of gestation) were studied by making serial histologic sections in the horizontal plane of the foot. It was observed that the shape of the medial cuneiform was altered and the first cuneometatarsal joint tilted toward the medial and dorsal directions. The first metatarsal appeared normal, whereas the other metatarsals were deformed in slight adduction at the metaphyseal level. Subluxation at the other cuneometatarsal joints and naviculocuneiform joint was not observed, and the navicular showed no signs of medial or lateral displacement in relation to the head of the talus. No histologic abnormalities of the joint capsules, ligaments, or tendons were observed. On the basis of these pathologic findings, the possibility of a developmental abnormality of the medial cuneiform as a pathogenic factor for the congenital metatarsus adductus deformity should be considered.

[Osteotomy of the smaller metatarsals]

A simple, oblique osteotomy at the distal third of the metatarsal shaft is described. It is a method of relieving the pain of prolapsed metatarsal heads incarcerated in the sole and often adherent to plantar skin. The procedure has a high success rate and has stood the test of time (over a quarter of a century).

Brachymetatarsia. Case report and surgical considerations

The authors present a case of congenital idiopathic brachymetatarsia of the fourth metatarsal. A combination of techniques was used to address the components of the deformity and its correction, which include preoperative soft tissue stretching, Z-skin plasty, Z-tendon lengthening, Z-lengthening metatarsal osteotomy with internal screw fixation, and bone allografting. Conventional autograft harvesting complications and external fixation were avoided. This case demonstrates the correction of a brachymetatarsal using combined and modified techniques.

Metatarsal lengthening by callotasis during the growth phase

Congenital or acquired shortness of a metatarsal may cause pain in adjacent metatarsals. From 1983 to 1990, we performed nine metatarsal lengthenings in seven adolescent patients by metaphyseal osteotomy followed by gradual distraction of callus (callotasis). Two patients required bone grafts after the lengthening. We used a rigid, unilateral external fixator designed for use in the hand and foot. At follow-up, from three to ten years later, healing had been achieved in all with an average healing index of 50 days/cm, and metatarsalgia had been relieved by the restoration of correct metatarsal length.

Chevron bone graft procedure for the correction of brachymetatarsia

Brachymetatarsia is a relatively rare condition, although there are many surgical procedures to correct the condition. The authors present a case study with a 2-year follow-up period demonstrating the successful surgical treatment of a 4th metatarsal brachymetatarsia of the left foot of a 14-year-old female. The operative technique and literature review are discussed. This technique combines the idea of bone grafting with a specific graft shape and donor site to facilitate graft stability and graft healing.

Abductory midfoot osteotomy procedure for metatarsus adductus

The authors describe a new surgical technique for the correction of metatarsus adductus using an abductory osteotomy performed in the lesser tarsal region that enables transverse plane correction of an adducted forefoot. This procedure is based on the premise that matatarsus adductus deformity is actually a deformity of the midtarsus rather than the metatarsus segment of the foot. The osteotomy technique involves shortening of the lateral column using closing wedge technique and lengthening of the medial column using opening wedge technique. The correction is entirely in the transverse plane; however, modifications may be performed when other planal deformities are present. Historical review, principles, technique, and case studies are discussed.

Treatment of brachymetatarsia using a semicircular lengthener. 1-3 years results in 6 patients

6 women with brachymetatarsia involving 9 bones were treated by the use of the Ilizarov semicircular lengthener. The affected bones were the second, third and fourth metatarsals. Ilizarov half-rings were applied on the foot with 5 or 6 half-pins (3 mm in diameter) and a percutaneous osteotomy was done. The short metatarsals were lengthened 0.25 mm twice a day by the patient. The lengthened distance was 15 (10-22) mm and the overall treatment time was 15 (12-25) weeks. The postoperative course was uneventful, with smooth bone regeneration. No bone-grafting was needed. During treatment, the patients could bear full weight and tolerated the fixators well. We conclude that this technique is useful in the treatment of brachymetatarsia.

Juvenile hallux abducto valgus association with metatarsus adductus

The authors evaluated the radiographs of 40 patients (72 feet) under 21 years of age who underwent surgery for symptomatic hallux abducto valgus deformity at Northlake Regional Medical Center. Forty-eight of 72 feet had metatarsus adductus angles greater than 15 degrees. A statistically significant correlation was found between an increasing metatarsus adductus angle and an increasing hallux abductus angle.

The long-term functional and radiographic outcomes of untreated and non-operatively treated metatarsus adductus

Thirty-one patients (forty-five feet) who had metatarsus adductus were evaluated at our institution and were followed for an average of thirty-two years and six months. Of these thirty-one patients, twenty-one (thirty-one feet) were examined clinically and radiographically. Information on the remaining ten patients (fourteen feet) was obtained by letter or telephone, or both. Twelve patients (sixteen feet) who had a passively correctable deformity (mild or moderate) at the time of the initial presentation had no treatment. Twenty patients (twenty-nine feet) who had a partly flexible or rigid deformity (moderate or severe) at the time of the initial presentation were managed with serial manipulation and application of plaster holding casts. (One patient who had a bilateral deformity had no treatment on one side and conservative management on the other). The results were good in all sixteen of the untreated feet and in twenty-six (90 per cent) of the twenty-nine feet that had been conservatively treated. There were no poor results. The passively correctable deformities resolved spontaneously. Radiographs showed an obliquity of the medial cuneiform-metatarsal joint in twenty-one (68 per cent) of the thirty-one feet that were examined clinically and radiographically. Similar findings were observed in four of eleven contralateral, normal feet. Hallux valgus was not a common outcome. No patient had operative correction.

Treatment of brachymetatarsia by callus distraction (callotasis)

Callus distraction (callotasis) has already become a popular procedure in the lengthening of limbs. With the development of a small device, it can also be applied to the hand or foot, thus providing benefits in the treatment of brachymetatarsia. Four toes of 3 patients with brachymetatarsia of the fourth toe were treated by this method, and excellent elongation of from 17.50 to 32.55 mm (average, 23.71 mm) was acquired. The treatment period ranged from 78 to 141 days (average, 112.5 days). More time was required in the earlier cases, but the most recent took only 11 weeks. The optimal distraction rate is considered to be 0.35 mm per half-day. Reshortening after treatment ranged from 3.6 to 5.5 mm (average, 4.7 mm), or from 15% to 26% (average, 20.5%) of the distracted length. About 90% of the resorption was observed within 1 month, except in a case that involved a postoperative fracture, and no resorption was seen after 2 surgical months. Regarding complications, subluxation of joints was seen in 2 patients and a postoperative fracture in 1 patient. Subluxation was caused by tendons resisting elongation. The procedure is described, representative cases are illustrated, and problems encountered are discussed.

Brachymetatarsia. Axial lengthening by using the callus distraction technique

The authors present a modified approach to the ilizarov callus distraction technique for bone lengthening on a patient with brachymetatarsia. This approach has certain advantages and disadvantages that will be discussed along with historical methods of treating brachymetatarsia. The actual case history, surgical technique, and perioperative care of the patient are described in detail.

Metatarsal epiphyseal bracket: treatment by central physiolysis

Longitudinal epiphyseal bracket (LEB) is a rare ossification anomaly in which an epiphysis brackets the diaphysis of a phalanx, metacarpal, or metatarsal. This abnormal epiphysis tethers longitudinal growth, resulting in a shortened and oval-shaped bone. Four patients with five LEBs were treated by central physiolysis and followed for a mean of 6 years. The patients had significant hallux varus deformity. Three patients had duplicated great toes, and two had tibia hemimelia significant enough to require epiphysiodesis as they neared adolescence. Resection of the LEB allowed the proximal and distal epiphysis to resume untethered growth. Silastic or methyl methacrylate was placed over the resected physis to prevent bony rebridging. The associated hallux varus deformity was corrected by capsulorrhaphy and K-wire fixation. In all patients, the metatarsal resumed longitudinal growth and correction of the hallux varus was maintained.

Structural metatarsus adductus deformity, surgical case report

Structural metatarsus adductus deformity may be corrected through the use of closing abductory base wedge osteotomies of all five metatarsals. Although technically demanding, surgical precision is increased through the use of oblique wedges and a combination of screw and cerclage wire fixation. In the severe case, an opening wedge osteotomy of the inner cuneiform (Fowler procedure), with homogenous bone implantation, may be concomitantly used. Both techniques are described in this brief case presentation.

Syndrome of microcephaly, Brachmann-de Lange-like facial changes, severe metatarsus adductus, and developmental delay: mild Brachmann-de Lange syndrome?

We report on 4 individuals (3 sibs and their father) with a syndrome of growth retardation, microcephaly, minor facial anomalies reminiscent of a mild Brachmann-de Lange syndrome (BDLS), severe metatarsus adductus, developmental delay, and unusual dermatoglyphics. The syndrome, which seems to be inherited as an autosomal dominant trait with variable expressivity, resembles mild BDLS.

Observer variability in the radiographic measurement and classification of metatarsus adductus

The classification system of Berg was evaluated using four observers and the radiographs of 42 feet from patients with metatarsus adductus. Interobserver disagreement in diagnosis was 36%. Intraobserver inconsistency averaged 26%. The error range for the lateral and anteroposterior talocalcaneal angle measurement was 13.6 and 15.1 degrees intraobserver and 19.8 and 25.2 degrees interobserver, respectively. There was no correlation between classification and the length of time required for cast correction. The irregularity of hindfoot ossification centers makes measurements inconsistent and seriously reduces the usefulness of classification based on such measurements.

Juvenile hallux valgus with compensated metatarsus adductus. Case report

The authors describe a case report of a patient with compensated metatarsus adductus and juvenile hallux valgus bilaterally. Treatment included closing base wedge abductory osteotomies of metatarsals one through five, modified McBride bunionectomy, Evans calcaneal osteotomy, and a percutaneous tendo Achillis lengthening. The patient maintained excellent correction on the right foot after 6 years. Hallux valgus recurred on the left foot after 2 years. The authors attribute this recurrence to a significant internal femoral torsion on the left leg. The significance of superstructural deformities on juvenile hallux valgus is discussed.

[High arched forefoot--pes cavus metatarsus congenitus. A case report]

This is a rare congenital deformity. Because of it's typical aspect the name "pes cavus metatarsus congenitus" was given. Complete operative correction is easily done.