Factors influencing treatment recommendations for base of 5th metatarsal fractures in orthopaedic residency programs

BackgroundManagement of proximal 5th metatarsal fractures remains a controversial topic in orthopaedic surgery. Both operative and non-operative approaches have been described in the clinical setting. This confusion has led to non-standardized treatment recommendations for proximal 5th metatarsal fractures. This study was designed to analyze concordance rate of treatment recommendations between orthopaedic trainees and orthopaedic foot and ankle experts.MethodsAn online survey containing 14 cases of proximal 5th metatarsal fractures were distributed to 92 orthopaedic residents in two ACGME-accredited programs. Relevant weight-bearing radiographs, patient’s age and gender were provided, and two questions regarding treatment recommendations were surveyed. Resident’s recommended treatment was then matched against ultimate treatment by orthopaedic foot and ankle experts. ANOVA and T-test are used for associations between the rate of concordant treatment with PGY and trainee foot and ankle experience. Fleiss’ kappa was used to assess the inter-observer agreement.ResultsSeventy-two residents returned the survey. The overall concordance rate was 43.98% with no correlation between agreement rate and PGY-years. No difference in agreement rate was observed between residents who had completed their foot and ankle rotation versus those who had not. There was a slight inter-observer agreement in recommending treatment among all residents (κ = 0.117, 95% CI: 0.071–0.184).ConclusionsOur data demonstrated no significant concordance between resident level in training regarding proximal 5th metatarsal fracture treatment decisions, nor between residents and subspecialty-trained foot and ankle surgeons. Increased rotations with foot and ankle fellowship-trained surgeons throughout residency may be desirable to improve the quality of residency training.Level of Evidence: III.     

Freiberg’s infraction: A modified closing wedge osteotomy for an undiagnosed case

IntroductionFreiberg’s infraction is an osteonecrosis affecting the metatarsal head whose pathogenesis is not fully understood, although stress overloading by multiple microtraumas remains the most widely accepted cause. Operative treatment, by different techniques, is necessary when conservative treatment fails.Presentation of caseA 31-year old woman presented with left foot severe pain, especially at the level of the metatarsophalangeal joint (MTPJ) of the second ray, underestimated upon initial evaluation. She had a history of repetitive microtraumas, a long second metatarsal bone and altered forefoot kinematics. Clinical and radiographic findings were compatible with Freiberg’s infraction. A dorsal closing-wedge osteotomy with single screw stabilization was performed. At last follow-up, the patient was completely asymptomatic with a normal MTPJ range of motion.DiscussionOur patient had a history of repetitive microtraumas combined with a long second metatarsal bone and altered forefoot kinematics. Initially, because of the low frequency of the disease and lack of knowledge about it, even among general orthopaedic surgeons, the infraction was not diagnosed. However, the radiological characteristics of the lesion, combined with intra-operative observation and histological exams associated with the medical history and clinical exam of the patient, revealed a disease compatible with Freiberg’s syndrome. A closing-wedge osteotomy, performed by using a straight burr, appeared to be the most correct treatment.ConclusionThis case shows how Freiberg’s infraction can pass unrecognized or underestimated and how dorsal closing-wedge osteotomy can be an efficient surgical treatment.     

Giant Solitary Osteochondroma Arising from the Fifth Metatarsal Bone: A Case Report

Accounting for 20% to 50% of all benign forms, solitary osteochondroma is the most common bone tumor. The long bones of the lower extremity are most frequently affected, whereas the small bones of the hands, feet, pelvis, scapula, and spine are less common locations. Osteochondromas are benign osseous neoplasms with a distinct hyaline cartilage cap originating from the physis, and they cease to grow with skeletal maturity. Treatment of osteochondroma is usually conservative, unless symptoms, usually pain, are progressive or the lesion demonstrates rapid or new growth, or if enlargement after skeletal maturation is noted or malignant transformation is suspected. In this report, we describe the case of an adult with a giant, symptomatic osteochondroma localized to the fifth metatarsal. The lesion was treated with excision, and after more than 2 years of follow-up, no evidence of recurrence was noted. This case demonstrated that, despite the benign nature of the lesion, a large osteochondroma could localize to a metatarsal.     

Clinical results of distal anterior tibial tendon decompression

BackgroundDistal tibialis anterior tendinopathy (DTAT) is condition which is infrequently described in literature and is usually treated with conservative means. If resistant to a rehabilitation protocol and unloading, a surgical treatment could be proposed. The aim of this research is to report on the history and clinical image of DTAT and present the clinical results of a simple surgical decompression of the tendon with local debridement and release of the distal extensor retinaculum.MethodsSeventeen patients diagnosed with DTAT in 18 feet underwent surgery between 2008 and 2018. Upon initial presentation, all patients reported a persistent history of pain over the tibialis anterior (TA) insertion. Ultrasound was routinely performed to confirm the diagnosis. In patients with confirmed diagnosis of DTAT, persistent despite conservative treatment, we proceeded with surgical intervention during which we released the tendon by opening the distal extensor retinaculum. Retrospective chart review was performed, and functional outcomes were assessed using the AOFAS midfoot score. AOFAS score results were collected postoperatively with at least one-year follow-up.ResultsAll patients experienced pain on palpation of the distal aspect of the TA tendon. Most patients experienced pain at night and were frequent hikers. Our study population consisted of mostly female and overweight patients. All patients reported pain relief with a significant improvement of VAS for pain from 6.7 ± 1.1 preoperatively to 1.1 ± 1.2 postoperatively (p < 0.05). The postoperative AOFAS midfoot score was 97 ± 3.7. Fifteen patients were completely satisfied, two satisfied with minor reservations.ConclusionSimple distal TA tendon release by division of a consistently present constricting distal extensor retinaculum represents a surgical alternative in the treatment of chronic DTAT. Our study shows good clinical outcomes with low complications.Level of EvidenceLevel IV – retrospective case series.     

Postoperative results of distal tibialis anterior tendinosis

IntroductionAlthough distal tibialis anterior tendinopathy is a common condition, it has rarely been described in literature. It is often a condition in overweight women around 50–70 years old with pain that worsens at night. The purpose of this retrospective study is to describe the specific clinical signs and postoperative results of distal tibialis anterior tendinopathy.Material and methodsBetween 2013 and 2017 we operated 9 patients (10 ft) who failed a conservative treatment of distal tibialis anterior tendinopathy. Surgery consisted of debridement of the diseased tendon and reinsertion with a bone anchor. There was a minimum follow-up of 12 months. All patients were clinically evaluated postoperative (range 14–57 months after surgery) with the use of the American Orthopaedic Foot and Ankle Society (AOFAS) score and Visual Analog Scale (VAS)ResultsThe mean AOFAS score postoperative was 99 (range 94–100). The mean VAS score postoperative was 1 (range 0–3). In all 10 cases the patient was completely satisfied with the result following surgery. There was no recurrence or rupture of tendon after debridement.ConclusionDistal tibialis anterior tendinopathy is mainly a clinical diagnosis where conservative treatment should always be the first choice. However, our results show that when conservative treatment fails, surgical treatment can lead to very good long term results with a high level of patient satisfaction.     

Osteochondrosis of the medial malleolar epiphysis: A case report and review of the literature

IntroductionOsteochondrosis is characterized by a disturbance of enchondral ossification in skeletally immature patients and should be investigated in children having a history of persistent foot and ankle pain. Involvement of the medial malleolar epiphysis is rarely reported.Presentation of caseWe describe the case of a sporty 12-year-old male with osteochondrosis of the left medial malleolar epiphysis treated with a conservative management.DiscussionCalcanear, navicular and metatarsal apophysis are the most common locations for osteochondrosis in ankle and foot. Anyway other osteochondrosis should be excluded. Medial malleolar osteochondrosis is occasionally described. We performed a review of the relevant literature and we summarized clinical aspects, radiological characteristics and reported management of this painful and probably underestimated condition.ConclusionMedial malleolar osteochondrosis is a rare but well recognized condition. Only seven cases are described in literature.     

The outcome of conservative treatment of fifth metatarsal diaphyseal fractures

IntroductionThe fifth metatarsal diaphyseal fracture is a common fracture. However, clear consensus about the treatment is lacking. Unlike the avulsion fracture or Jones’ fracture, literature available on the treatment and long-term outcome of the diaphyseal fracture is scarce.The purpose of this study is to demonstrate a substantial number of conservatively treated patients with persistent pain and to evaluate metatarsal shortening and displacement within this group.MethodsIn this retrospective study, 106 patients who had experienced a fifth metatarsal diaphyseal fracture were included and evaluated. The minimum follow-up period was three months. FAAM, AOFAS and NRS scores were used as outcome measurements for function and pain. Length and displacement were analysed on plain X-rays.ResultsAt least 11% of the patients who received conservative treatment for their fifth metatarsal diaphyseal fracture had persistent pain at least 3 months after initiation of conservative treatment. No relationship has been found between the length of the fifth metatarsal and the FAAM (r( Petrisor et al., 2006) 2 = 0,051), AOFAS (r( Petrisor et al., 2006) 2 = 0,009) and NRS (r( Petrisor et al., 2006) 2 = 0,001). Furthermore, there was no association between patients with a shorter fifth metatarsal and FAAM, AOFAS, NRS, displacement and BMI.Discussion and conclusionThe finding of persistent pain in at least 11% of all patients at long-term follow-up confirms our hypothesis on long-term symptoms. However, the results suggest that these persistent symptoms are not related to metatarsal shortening or displacement.     

Osteochondromas around the ankle: Report of a case and literature review

INTRODUCTIONAn osteochondroma or exostosis is a benign bone tumour consisting of a bony outgrowth covered by a cartilage cap that occurs commonly in the metaphysis of long bones, mainly the distal femur, proximal tibia and proximal humerus.PRESENTATION OF CASEWe describe an unusual case of a distal tibia osteochondroma affecting the lateral malleolus of a young girl.DISCUSSIONMost osteochondromas are asymptomatic and seen incidentally during radiographic examination. Osteochondromas are rarely localized in the foot and ankle.CONCLUSIONAlthough most of the osteochondromas in children should be treated conservatively until skeletal maturity, those affecting the distal tibia or fibula should be treated with surgical excision in order to prevent ankle deformity, syndesmotic lesions or even fracture due to the expanding nature of this benign tumour.     

Longitudinal Epiphyseal Bracket of the First Metatarsal Bone: Three Case Reports and a Review of the Literature

Longitudinal epiphyseal bracket (LEB) is a rare bone dysplasia of the tubular bones. Owing to an abnormal secondary ossification center, the affected bones can develop progressive shortening and angular deformity. The aim of our study was to provide an overview of the reported data regarding epidemiology and surgical procedures available for LEB of the first metatarsal bone in a pediatric population combined with a small case series. We report a retrospective case series of 3 nonsyndromic pediatric patients with different ages and with confirmed dysplasia of the first metatarsal bone. All patients presented with unilateral congenital hallux varus deformity and underwent surgical treatment. The radiographs and medical records were reviewed to evaluate the deformity characteristics, treatment, and clinical results. The mean patient age at initial surgery was 34 (range 12 to 63) months, and the median follow-up period was 46 (range 31 to 75)?months. Almost all specific radiographic measurements showed correction of the deformity, and each foot demonstrated functional and cosmetic improvement. A standardized literature search was performed to obtain studies of LEB of the first metatarsal bone in the pediatric population. From on our results and the current data available, surgical treatment should be tailored to the patient's age and radiographic stage of LEB. However, monitoring until skeletal maturity of the feet is necessary to assess the final results.     

Fracture or Variation in Distal Phalanx of the First Toe

Abstract Background: Variations of the epiphyseal ossification of short tubular bones were repeatedly mistaken for fractures. Case Study: The case of an 11–year-old male patient after a minor trauma is presented. An extra ossification center at the epiphysis of the distal phalanx of the first toe was diagnosed as a fracture and treated appropriately. The recovery was very fast, about 4 days. 3 years later the extra ossification center was still visible and a parted epiphysis of the proximal phalanx appeared again like a fracture, but with no clinical symptoms in that region. This time after a minor trauma, there was no treatment and the patient was free of symptoms after 1 week. Conclusion: The variation range of the ossification centers of the first toe is wide. In minor trauma X–ray findings should correlate exactly with the symptoms not to overdiagnose toe fractures.     

多学科诊疗模式下以不同方法治疗肺动静脉畸形

目的 观察多学科诊疗（MDT）模式下以不同方法治疗肺动静脉畸形（PAVM）的有效性及安全性。方法 对31例PAVM患者行MDT,对比介入治疗、手术治疗及保守治疗用于PAVM的有效性及安全性。结果 31例中,22例接受介入治疗（介入组）,4例接受手术治疗（手术组）,5例接受保守治疗（保守组）。介入组22例均成功栓塞PAVM,技术成功率100%（22/22）;3例出现胸膜炎（3/22,13.64%）,随访期间4例PAVM复发（4/22,18.18%）,经二次介入治疗后均未复发。手术组4例均成功行胸腔镜下病变肺叶切除术,技术成功率100%（4/4）,均未出现术后并发症;随访期间2例PAVM复发（2/4,50.00%）,1例接受介入治疗、1例接受保守治疗。保守组5例中,3例PAVM进展（3/5,60.00%）;其中2例经介入治疗后未复发、1例接受保守治疗后死于脑卒中。结论 MDT模式下以不同方法个体化治疗PAVM具有可行性;相比手术及保守治疗,介入治疗PAVM更为有效且相对安全。     

Recurrence after correction of acquired ankle equinus deformity in children using Ilizarov technique

To describe our Ilizarov technique for the treatment of acquired equinus deformity in children and to determine if compliance with continuous use of an ankle foot orthosis (after removal of the fixator and until skeletal maturity) can influence the severity of recurrence. A cohort of 26 children with post-traumatic or post-burn contractures producing an equinus deformity was followed up for a minimum of 2 years after skeletal maturity. Cases with a bony deformity and/or nerve injury were excluded from this study. All patients were managed by a percutaneous tendo-Achilles lengthening followed by application of an Ilizarov external fixator. Post-operative treatment was in the form of gradual correction at a rate of 0.5 mm per day. Correction started from the second postoperative day until an over-correction of 15 degrees dorsiflexion was achieved. Ankle range of movement was encouraged 4 weeks prior to removal of the external fixator. On removal of the fixator, a posterior splint was applied until substituted by an ankle foot orthoses (AFO). The AFO was used continuously during the first 2–3 months and at nighttime thereafter until skeletal maturity. Fifteen children were compliant with the use of the AFO until skeletal maturity and 11 non-compliant. We compared the recurrence and the size of deformity between the two groups. The rate of recurrence, degree of equinus at recurrence and number of episodes of external fixation surgery showed statistical significant differences (P < 0.01) between the groups. The Ilizarov technique for treatment of acquired equinus deformity secondary to soft tissue scarring is a safe and effective technique. The use of an AFO until skeletal maturity can decrease the risk and degree of recurrence.     

Preossified longitudinal epiphyseal bracket of the foot: treatment by partial bracket excision before ossification

The longitudinal epiphyseal bracket is a rare ossification defect of tubular bones in the hand and foot. This deformity contains an abnormal secondary ossification center, which may lead to progressive shortening and angular deformity of involved bones. This article describes the results from early treatment of this deformity before the secondary ossification center ossifies. Four patients with seven involved bones (5 metatarsals and 2 phalanges) were treated with surgical excision of the longitudinal epiphyseal brackets, without corrective osteotomy. The average age at surgery was 16 months (range, 6-20 months), and the average follow-up period was 55 months (range, 31-80 months). All five metatarsal patients demonstrated progressive improvement in the deformity. Of the two phalanx patients, one improved and the other did not. Early treatment of the longitudinal epiphyseal bracket before ossification of the secondary center with excision is effective in correcting this deformity. Long-term follow-up assessment until skeletal maturity is necessary to assess the final results of surgery because corrective osteotomy may be necessary for patients who do not have adequate correction.     

Osteopathic treatment for cam-type Femoroacetabular impingement syndrome: A case report

BackgroundFemoroacetabular impingement (FAI) syndrome treatment is initially conservative, but the number of studies is limited.ObjectivesTo examine the results of an osteopathic treatment approach in a patient with FAI.Clinical featuresThe evaluation and osteopathic treatment of an 18-year-old male athlete diagnosis of left hip cam-type FAI are presented.Intervention and outcomesExercises and protective measures were applied together with osteopathic techniques. Treatments were applied for 6 weeks, two days a week for a total of 12 sessions. The Numerical Evaluation Scale was used for pain evaluation. Functional scores were obtained by the Harris Hip Score, and deep squat test. Muscle strength was measured using the Handheld Dynamometer. Short Form-36 was used for the assessment of the quality of life. The final evaluations showed improvement in pain, function, muscle strength, and symptom-specific test results. Three weeks after the treatment, the patient made a complete return to sports, and there was no recurrence in the first year after treatment.ConclusionOsteopathic therapy may be effective in the conservative treatment of FAI. Well-designed clinical trials are needed to further evaluate this conclusion.     

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

IntroductionThis 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).MethodsProspective 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 12 months 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).ResultsClaw 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.DiscussionThese 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.     

Talocalcaneal coalition in a 15 year old female basketball player

This case reports an adolescent athlete with activity related chronic bilateral dorsal foot pain and stiffness. A 15 year old competitive female basketball player presented to a chiropractor subsequent to an unsuccessful course of conservative treatment for posterior tibial dysfunction. The patient's plain films were incorrectly read as normal and a CT scan obtained by the radiologist called the findings bilateral osteoarthritis. The patient was awaiting a referral to a rheumatologist at the time of initial consultation with the chiropractor. Examination revealed limited subtalar mobility and review of the images revealed bilateral non-osseous talocalcaneal coalition. The patient was subsequently directed to a pediatric orthopedic surgeon and is scheduled for a resection of the coalition. Primary care practitioners should be aware of this uncommon, but not rare, variable clinical presentation as misdiagnosis and mismanagement could lead to suboptimal patient outcomes. To our knowledge this is the first case report of a patient with tarsal coalition published in chiropractic literature. In addition, this case is the first to report radiographic evidence of chronic mechanical stress to the second metatarsal associated with tarsal coalition.     

Surgical excision of heterotopic ossification associated with anti-N-methyl-d-aspartate receptor encephalitis: A case report

Introduction and importanceHeterotopic ossification (HO) associated with Anti-N-methyl-d-aspartate (anti-NMDA) receptor encephalitis is rare and the treatment strategy is unclear.Case presentationWe report the case of a 31-year-old female diagnosed with anti-NMDA receptor encephalitis from Osaka General Medical Center, Osaka, JAPAN that developed heterotopic ossification of the knees during prolonged coma. She was unable to walk because of pain and limited range of motion in both knees. Thirty months after the onset of the coma, surgical excision of the heterotopic bone in both knees was performed. The range of motion of both the knees improved markedly and she had no recurrence of heterotopic ossification on a three-year follow-up. Thus, this case can be used as a guide for surgeons with such patients.ConclusionsWe reported a case of heterotopic bone formation in the periarticular region of both bilateral knees in a patient who suffered a 2-month coma following anti-NMDA receptor encephalitis. Surgical excision of the heterotopic bones significantly improved the passive range of motion in both knees. Three years after the operation, the patient had no complaints about her knees, and there was no recurrence of HO.     

Distal metatarsal synostosis: A case report

We report a rare case of distal metatarsal synostosis of the 4th and 5th metatarsals in an 11 year old male. He was referred with forefoot pain. Clinical examination and radiographs have confirmed an osseous connection of the distal 4th and 5th metatarsal. This was treated surgically with bony bridge excision and the patient is now asymptomatic.     

Iatrogenic fracture gapping during fixation of Jones fractures: Anatomic and mechanical considerations in a cadaveric model

BackgroundSurgical fixation of Jones fractures is often recommended to facilitate recovery and achieve union. Iatrogenic fracture displacement during intramedullary screw fixation is a commonly encountered technical issue. This may be related to fracture location in relation to the surrounding ligamentous attachments, namely the robust intermetatarsal ligaments found at the proximal articulation of the 4th and 5th metatarsals. This study examines the relationship between fracture line and its location in regards to the surrounding ligamentous structures and its effect on Jones fracture displacement, reduction and fixation in a cadaveric model.MethodsEighteen fresh-frozen cadaveric feet were dissected with preservation of all ligamentous attachments. Given the similar anatomic distal extent of the dorsal and plantar intermetatarsal ligaments on the 5th metatarsal, measurements were obtained detailing the anatomic position of the dorsal intermetatarsal ligament (DIL) only. The specimens were divided into two groups with modelled fractures created at the 4th & 5th metatarsal articulation proximal to the distal extent of the DIL (Group 1) or just distal to the DIL (Group 2). Fractures were fixed in standard fashion with serial fluoroscopic images obtained to study fracture gapping and rotation.ResultsThere was approximately 5 mm of fracture gapping created iatrogenically during tapping with no statistically significant differences between Group 1 and Group 2 (4.53 mm versus 5.25 mm, p = 0.5430). The distal aspect of the DIL was anatomically located 2.77 mm (Range 1.58 mm–4.46 mm) distal to the 4th & 5th metatarsal articulation.ConclusionsConsiderable iatrogenic fracture gapping occurs during intramedullary screw fixation of Jones fractures in a cadaveric model regardless of fracture location in relation to the intermetatarsal ligamentous attachments. Specific techniques may be required to maintain anatomic alignment during tapping and screw fixation to prevent iatrogenic displacement.Level of evidenceV, Expert Opinion.     

第1跖骨远端Chevron截骨联合软组织松解术治疗拇外翻

目的 :探讨第1跖骨远端Chevron截骨联合软组织松解术治疗轻、中度拇外翻的临床疗效。方法:自2015年6月至2017年6月,采用第1跖骨远端Chevron截骨联合软组织松解术治疗拇外翻32例(40足),其中男3例3足,女29例37足;年龄22～80岁,平均57.57岁;病程2～32年,平均14年;轻度9足,中度31足。术前患者合并拇囊炎,伴有第1跖趾关节周围疼痛并存在负重行走时疼痛加重。手术前后拍摄足负重正侧位片,比较拇外翻角(hallux valgus angle,HVA),第1、2跖骨间角(intermetatarsal angle,IMA),并采用美国足踝外科协会拇外翻评分(AOFAS)评价临床疗效。结果:32例患者获得了随访,时间12～24个月,平均15.2个月。术后切口均愈合良好,无感染、跖骨头坏死等并发症发生。术前HVA、IMA分别由(32.08±5.59)°、(11.63±2.24)°减小至术后12个月的(10.31±4.36)°、(5.02±2.34)°,差异有统计学意义(P0.05)。AOFAS评分由术前的56.75±6.42提高至术后12个月的88.80±3.99 (P0.05)。结论:第1跖骨远端Chevron截骨联合软组织松解术治疗轻、中度拇外翻畸形可获得较好的临床效果,为拇外翻治疗提供了更多的选择。