Isolated slipped-retroverted osteochondral fracture of second metatarsal head

Although metatarsal fractures are common, isolated intraarticular metatarsal head fractures are rare, and retroversion of the fracture segment is even rarer. Herein, a retroverted fracture of the second metatarsal head, which happened with a direct trauma from jumping from a height, was discussed with treatment options and finally a simple surgical trick was advised. There are only a few cases of isolated osteochondral and retroverted fractures of the metatarsal head in literature. The following is a rare case report of such an injury in a 19-year-old male.     

Subchondral insufficiency fracture of the second metatatarsal head in an eldery woman treated with autologous osteochondral transplantation

Freiberg's infraction is a rare disorder that arises mostly in adolescent athletes. We describe a 77-year-old woman with the collapse of second metatarsal head with similar clinical appearance to Freiberg's infraction. Radiological findings at initial visit of our hospital were normal. Her condition was obscure and magnetic resonance imaging showed the subchondral insufficiency fracture with bone marrow edema to the second metatarsal head. Despite the conservative treatment, the second metatarsal head collapsed. She was surgically treated with an osteochondral autograft without complications relating surgery. Furthermore, the histological findings showed that the site of collapse was considered to be secondary lesions resulting from the subchondral insufficiency fracture.     

A simple method for repositioning metatarsal fractures]

Because of small direct contact to the fracture fragments reduction of metatarsal fractures can be achieved only indirectly by applying traction to the toes. In this article a method for simple direct manipulation of the distal main fragment of metatarsal fractures is described: A K-wire is drilled in dorsi plantar direction across the head of the fractured metatarsal and mounted on a traction bow. In this manner the distal fracture fragment can be moved in all directions and placed exactly onto the proximal fragment. All 8 patients with multiple metatarsal fractures could be treated by closed reduction and percutaneous pinning. The described method allows simple and precise reduction of metatarsal fractures, reduced x-ray exposure of the surgeon's hand by short operation times, and manipulation for fracture reduction outside the x-ray beam.     

Radial head arthroplasty using a metatarsal osteochondral autograft

Purpose

Treatment of comminuted fractures of the radial head is controversial, and considerable effort has been made to restore optimal function of the elbows, either by surgical reconstruction or prosthetic replacement. This report presents our experiences in treatment of unreconstructable radial head or neck fractures using osteochondral autografts harvested from the base of the second metatarsal bones.

Methods

Five patients with radial head and one with a radial neck fracture underwent treatment with osteochondral autografts. After excision of the unreconstructable radial head, the second metatarsal base was harvested and transplanted to the radius using the intramedullary nailing technique.

Results

The reconstructed elbows were examined clinically and radiographically for a mean period of 44.8 months (range, 24–72 months). At the last follow-up, in flexion-extension, the mean elbow mobility was 130°/10°. In supination-pronation, the mean elbow mobility was 73.3°/66.7°, with a mean loss of supination of 19.2° and loss of pronation of 12.5°. Grip strength was 91%, compared with the contralateral limb. The mean Mayo Elbow Performance Score was 94.2. The mean score of AOFAS rating system to the lesser toe was 93.7 points.

Conclusion

Radial head arthroplasty with an osteochondral autograft from the second metatarsal base appears to be an effective alternative for treatment of unreconstructable radial head fractures. A larger group of patients and a longer follow-up period will be required in order to ease concerns regarding the donor site; however, none of the patients who underwent this procedure showed any complications during follow-up.     

Autogenous osteochondral transplantation of the second metatarsal head

A case of an osteochondral defect of the second metatarsal head treated with autogenous osteochondral transplantation from the talonavicular joint is presented. At 6-months follow-up, the patient had returned to previous activities with no complaints. MRI evaluation showed good congruency of the joint surface and complete incorporation of the osteochondral autograft.     

Management of posterior fracture-dislocations of the shoulder

Posterior fracture-dislocation of the shoulder is rare. Comprehensive treatment guidelines for posterior fracture-dislocation of the shoulder with fracture of the humeral head have not been previously published. Although open reduction and internal fixation of the proximal humerus for posterior fracture-dislocation has been reported in several series, the successful reconstruction of the articular surface by rigid internal fixation of a large osteochondral fragment has not been reported. This paper describes two cases of posterior fracture-dislocation of the shoulder with a substantial defect of the anteromedial humeral head resulting from the cleavage of a large osteochondral fragment. Preoperative computed axial tomographic (CAT) scanning of the injured shoulders helped in operative planning by precisely defining the extent of the articular injury. Accurate reconstruction of the articular surface restored joint stability and gave excellent clinical results. Large humeral head osteochondral fracture fragments require accurate reduction and internal fixation.     

Metaizeau's technique for displaced metatarsal neck fractures

Metaizeau's technique can be applied to reduce the displaced metatarsal head distally from the fracture in an easier way and to keep the fracture site closed, as compared with retrograde Kirschner wires. We present seven fractures treated anterograde with progressive weight-bearing after 2 weeks. Open reduction was unnecessary in all cases. This technique permitted correct control of the distal fracture fragment, obtained good reduction of the metatarsal heads without opening the fracture site, and with no lesion of the capsulo-ligamentosus metatarsophalangeal joint structures. We obtained the radiographic healing of all and showed correct alignment. Metaizeau's technique is a valid alternative to retrograde Kirschner wires fixation in the treatment of displaced metatarsal neck fractures.     

Freiberg's disease

Freiberg’s disease is a relatively uncommon disorder of the metatarsal head. Although trauma and circulatory disturbances likely contribute major roles in its development, it is widely accepted that Freiberg’s etiology is multifactorial. Conservative treatment, focused on offloading and relieving stress, is uniformly accepted as the appropriate initial management. Surgical management can broadly be categorized as procedures which attempt to correct the pathophysiology and halt its progression, and procedures which address the sequelae of later stage disease. Newer strategies, including osteochondral transplantation, attempt to restore the damage metatarsal cartilage with a viable osteochondral plug.     

Traumatic osteochondral defect of the first metatarsal head: a case report.

Osteochondral injury of the first metatarsophalangeal joint is described in most literature as "osteochondritis dissecans" and an early stage of hallux rigidus. Traumatic osteochondral lesions of the knee and ankle are relatively common and well described. A case of a traumatic osteochondral defect of the first metatarsal head is presented.     

Sesamoid disorders of the first metatarsophalangeal joint

The sesamoid complex is located centrally and plantar to the first metatarsal head, where they are imbedded within the plantar plate, which transmits 50% of body weight and more than 300% during push-off, is susceptible to numerous pathologies. These pathologies include sesamoiditis, stress fracture, avascular necrosis, osteochondral fractures, and chondromalacia, and are secondary to these large weight-bearing loads. This article discusses sesamoid conditions and their relationship with hallux limitus, and reviews the conditions that predispose the first metatarsophalangeal joint to osteoarthritic changes.     

Surgical management of osteochondral lesions of the first metatarsal head: A systematic review

BackgroundTreating osteochondral lesions of the first metatarsal head can help reducing pain and preventing end-stage arthritic cartilage degeneration and hallux rigidus. Several surgical techniques have been described, but no clear indications are reported. This systematic review aims to offer an overview of the current surgical treatments for focal osteochondral lesions of the first metatarsal head.MethodsThe selected articles were examined to extract data about population, surgical technique, and clinical outcomes.ResultsEleven articles were included. Mean age at surgery was 38,2 years. Osteochondral autograft was the most used technique. After surgery, an improvement was achieved in AOFAS, VAS, and hallux dorsiflexion but not in plantarflexion.ConclusionThere is limited evidence and knowledge regarding the surgical management of the first metatarsal head osteochondral lesions. Various surgical techniques have been proposed, drawn from other districts. Good clinical results have been reported. Further high-level comparative studies are necessary to design an evidence-based treatment algorithm.     

Osteochondral autogenous transplantation for an osteochondral defect of the first metatarsal head: A case report

A case of an isolated, traumatic, osteochondral injury to the articular surface of the first metatarsal head, which was successfully treated with an autogenous transplant of an osteochondral plug from the ipsilateral knee, is reported. After a 2-year follow-up, the patient reported no persistent symptoms, full resumption of preinjury activities, and was satisfied with her outcome.     

Osteochondral Autograft Transfer of the First Metatarsal Head: A Case Report

A case of an osteochondral autograft transfer performed at the head of the first metatarsal for an acute incidence of traumatic osteochondritis dissecans was presented. The donor site for the osteochondral graft was from the medial and plantar aspect of the talar head, which was found to be composed entirely of articular hyaline cartilage, yet was not part of the functional talonavicular articulation. Six months postoperatively, the graft was well seated at the head of the first metatarsal, as confirmed by magnetic resonance imaging, and the graft donor site was asymptomatic. At 12 months' follow-up, the patient had a functional metatarsophalangeal joint range of motion. Details from the case study as well as a review of the literature are presented.     

Osteochondral defects of the first metatarsal head in adolescence: a stage in the development of hallux rigidus

The cases are presented of five adolescents in whom there was an osteochondral defect of the first metatarsal head. The significance of this lesion is discussed.     

Acetabular posterior wall fracture 38 cases followed for 5 years

Thirty-eight patients with a fracture of the posterior wall of the acetabulum were reviewed after 5 (2-12) years. Of 18 patients with successfull manuel reduction of a femoral head dislocation, a small fracture fragment, no sciatic nerve injury and who were not operated on, 17 had a good result. Of 20 patients who were operated on either because of the large size of the fracture fragment or because of a persistent dislocation of the femoral head, 6 had a poor result due to femoral head necrosis. In these 6 patients the reduction had been delayed and the acetabular osteochondral lesion was more severe than in the other patients. Skeletal traction seems unnecessary in the treatment of acetabular posterior wall fracture.     

Acetabular posterior wall fracture. 38 cases followed for 5 years

Thirty-eight patients with a fracture of the posterior wall of the acetabulum were reviewed after 5 (2-12) years. Of 18 patients with successful manual reduction of a femoral head dislocation, a small fracture fragment, no sciatic nerve injury and who were not operated on, 17 had a good result. Of 20 patients who were operated on either because of the large size of the fracture fragment or because of a persistent dislocation of the femoral head, 6 had a poor result due to femoral head necrosis. In these 6 patients the reduction had been delayed and the acetabular osteochondral lesion was more severe than in the other patients. Skeletal traction seems unnecessary in the treatment of acetabular posterior wall fracture.     

The Results of Operative Teatment for Recurrent Dislocation of the Gleno-Humeral Joint

Thirty-eight patients with a fracture of the posterior wall of the acetabulum were reviewed after 5 (2-12) years. Of 18 patients with successfull manuel reduction of a femoral head dislocation, a small fracture fragment, no sciatic nerve injury and who were not operated on, 17 had a good result. Of 20 patients who were operated on either because of the large size of the fracture fragment or because of a persistent dislocation of the femoral head, 6 had a poor result due to femoral head necrosis. In these 6 patients the reduction had been delayed and the acetabular osteochondral lesion was more severe than in the other patients. Skeletal traction seems unnecessary in the treatment of acetabular posterior wall fracture.     

A Novel Technique to Treat Hallux Rigidus in Athletic Patients With Central Osteochondral Defects: Preliminary Report on 12 Cases

Osteochondral defects, often caused by traumatic injuries, are focal areas of articular damage resulting in joint pain and stiffness ultimately leading to degenerative joint disease. This has not been well studied in the first metatarsal head, but is an often encountered problem in the active population in other joints. In this study, we prospectively evaluated the results of 12 patients who received autogenous bone grafting for repair of osteochondral defects of the first metatarsal head. Clinical outcomes were evaluated by the visual analog scale for pain and the Roles and Maudsley (RM) score. Between the years of 2009 and 2016, 12 patients received treatment for this particular surgical intervention and their outcomes were measured. The patients’ average age was 43.5 ± 10.6 years and were followed from 52.3 ± 26.7 months postoperatively. Average return to activity was 4.7 ± 1.1 months. The average preoperative RM score was 4.0 ± 0.0 and postoperative RM score was 1.4 ± 0.7 (p = .0001). The encouraging outcomes of this study suggest that autogenous bone grafting for osteochondral defects of the first metatarsal head is an effective treatment to help restore the function of the first metatarsophalangeal joint.     

Closed Transverse Pinning for Reduction and Fixation of Metatarsal Neck Fractures: Surgical Technique

Most metatarsal neck fractures can be successfully treated non-operatively in a cast boot. Displaced metatarsal neck fractures tend to be less stable and have a propensity for the distal fragment to angulate, secondary to the strong flexor tendons, which often forces the distal fracture fragment in a plantar direction and leads to relative metatarsal shortening. Most literature is focussed on antegrade fixation of metatarsal neck fractures using pre-bent K wires or thin elastic nails. Apart from the technical challenges, this technique is limited when bones are osteoporotic as the pre-bent distal end of the K-wire may penetrate the plantar cortex of the proximal metatarsal and prevent the wire from entering the medullary canal of the metatarsal and advancing to the fracture site. Furthermore, when the medullary canal is narrow especially in Asian patients, it may be difficult to pass a bent K-wire through the isthmus of the metatarsal shaft. We describe an innovative technique of closed transverse wiring of the metatarsal head necks that has a distinct advantage in Asian population with osteoporotic bones. With percutaneous manipulation using digital pressure, closed reduction of fracture fragments of the most displaced fracture is done under fluoroscopic guidance to achieve a satisfactory alignment followed by closed transverse wiring of the metatarsal heads. With this procedure, adjacent fractures remain stable within an acceptable range because of intermetatarsal ligaments connected to the adjacent intact head. Our technique has a relatively short operating time and allows for early motion of the metatarso-phalangeal joint. This is especially useful for those with osteoporosis, narrow canal, soft tissue compromise, intra-operative failure of ante-grade pinning and in scenarios of limited surgical equipment/expertise.