Biomechanical consequences of adding plantar fascia release to metatarsal osteotomies: Changes in forefoot plantar pressures

Destruction of the normal metatarsal arch by a long metatarsal is often a cause for metatarsalgia. When surgery is warranted, distal oblique, or proximal dorsiflexion osteotomies of the long metatarsal bones are commonly used. The plantar fascia has anatomical connection to all metatarsal heads. There is controversial scientific evidence on the effect of plantar fascia release on forefoot biomechanics. In this cadaveric biomechanical study, we hypothesized that plantar fascia release would augment the plantar metatarsal pressure decreasing effects of two common second metatarsal osteotomy techniques. Six matched pairs of foot and ankle specimens were mounted on a pressure mat loading platform. Two randomly assigned surgery groups, which had received either distal oblique, or proximal dorsiflexion osteotomy of the second metatarsal, were evaluated before and after plantar fasciectomy. Specimens were loaded up to a ground reaction force of 400 N at varying Achilles tendon forces. Average pressures, peak pressures, and contact areas were analyzed. Supporting our hypothesis, average pressures under the second metatarsal during 600 N Achilles load were decreased by plantar fascia release following proximal osteotomy (p < 0.05). However contrary to our hypothesis, peak pressures under the second metatarsal were significantly increased by plantar fascia release following modified distal osteotomy, under multiple Achilles loading conditions (p < 0.05). Plantar fasciotomy should not be added to distal metatarsal osteotomy in the treatment of metatarsalgia. If proximal dorsiflexion osteotomy would be preferred, plantar fasciotomy should be approached cautiously not to disturb the forefoot biomechanics. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:800–804, 2017.

     

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

BackgroundPlantar pressure distribution after the first metatarsal proximal crescentic osteotomy (FMPCO) with lesser metatarsal proximal shortening osteotomy (LMPSO) for hallux valgus with metatarsalgia has not been previously described.MethodsThe pre- (Pre) and postoperative (Post) groups comprised of 18 patients who underwent unilateral FMPCO with LMPSO; fifteen healthy volunteers constituted the control (C) group. For each of the 10 regions, peak pressure (Peak-P), maximum force (Max-F), contact time (Con-T), contact area (Con-A), and force-time integral (FTI) were measured.ResultsThe mean Peak-P of the second metatarsal head was significantly lower in the Post group than the Pre group. The mean Peak-P, Max-F, Con-T, and FTI were not significantly different between the Post and C groups. The mean Con-A was significantly lower in the Post group than the C group.ConclusionFMPCO with LMPSO may improve the plantar pressure of the central forefoot comparable to healthy subjects.     

Shortening Proximal Chevron Metatarsal Osteotomy for Patients With a Hallux Valgus Deformity With Advanced Arthritis

To correct hallux valgus deformities in patients with advanced arthritis of the first metatarsophalangeal joint, we designed a new reverse chevron-type shortening osteotomy technique that could be used to correct valgus deformities at the proximal metatarsal level, as well as shorten and lower the metatarsal, in a 1-time procedure. Sixteen feet in 16 patients with a minimum of 18 months follow-up who underwent a shortening proximal chevron metatarsal osteotomy for a hallux valgus deformity with advanced arthritic change between January 2014 and March 2016 were reviewed in this study. Double chevron osteotomies with 20° of plantar-ward obliquity at the proximal metatarsal level were made at 5-mm intervals for simultaneous valgus correction and metatarsal shortening. An additional Weil osteotomy of the second metatarsal was performed in all feet. Patients’ mean age was 57.88 ± 6.55 years. The deformity was satisfactorily corrected by the operation. The first metatarsal was shortened by approximately 8.75 mm, and the relative length of the second metatarsal did not differ significantly postoperatively (p?=?.179). The relative second metatarsal height, as seen on forefoot axial radiographs, was maintained constantly, with no significant difference (p?=?.215). No painful plantar callosity or transfer metatarsalgia under the second metatarsal head was observed postoperatively. A shortening proximal chevron metatarsal osteotomy for hallux valgus deformities with advanced arthritic change showed a good result with respect to deformity correction and pain relief. Appropriate lowering and an additional Weil osteotomy effectively prevented postoperative pain and painful callosity under the second metatarsal head.     

Effect of metatarsal pad placement on plantar pressure in people with diabetes mellitus and peripheral neuropathy

BACKGROUND: Standard prevention and treatment strategies to decrease peak plantar pressure include a total contact insert with a metatarsal pad, but no clear guidelines exist to determine optimal placement of the pad with respect to the metatarsal head. The purpose of this study was to determine the effect of metatarsal pad location on peak plantar pressure in subjects with diabetes mellitus and peripheral neuropathy. METHODS: Twenty subjects with diabetes mellitus, peripheral neuropathy, and a history of forefoot plantar ulcers were studied (12 men and eight women, mean age=57+/-9 years). CT determined the position of the metatarsal pad relative to metatarsal head and peak plantar pressures were measured on subjects in three footwear conditions: extra-depth shoes and a 1) total contact insert, 2) total contact insert and a proximal metatarsal pad, and 3) total contact insert and a distal metatarsal pad. The change in peak plantar pressure between shoe conditions was plotted and compared to metatarsal pad position relative to the second metatarsal head. RESULTS: Compared to the total contact insert, all metatarsal pad placements between 6.1 mm to 10.6 mm proximal to the metatarsal head line resulted in a pressure reduction (average reduction=32+/-16%). Metatarsal pad placements between 1.8 mm distal and 6.1 mm proximal and between 10.6 mm proximal and 16.8 mm proximal to the metatarsal head line resulted in variable peak plantar pressure reduction (average reduction=16+/-21%). Peak plantar pressure increased when the metatarsal pad was located more than 1.8 mm distal to the metatarsal head line. CONCLUSIONS: Consistent peak plantar pressure reduction occurred when the metatarsal pad in this study was located between 6 to 11 mm proximal to the metatarsal head line. Pressure reduction lessened as the metatarsal pad moved outside of this range and actually increased if the pad was located too distal of this range. Computational models are needed to help predict optimal location of metatarsal pad with a variety of sizes, shapes, and material properties.     

Proximal oblique-domed osteotomy of the first metatarsal for the treatment of hallux valgus associate with flat foot: effect to the correction of the longitudinal arch of the foot

Introduction Flat foot and/or metatarsal primus varus are the major causes of hallux valgus, and it is important to correct these deformities in order to prevent the recurrence of this condition. We demonstrate the clinical and radiological assessment of the correction of hallux valgus, metatarsal primus varus, and flat foot after proximal oblique-domed osteotomy of the metatarsus with distal soft tissue reconstruction. Materials and methods Twenty-seven feet of 22 patients with moderate or severe hallux valgus who had undergone proximal oblique-domed osteotomy were studied. After the adductor hallucis tendon was cut at the attachment of the proximal phalanx and at the sesamoid bone, the osteotomy was performed 3 cm dorsal-distal to the metatarsocuneiform joint to transfer distal fragment approximately 5 mm in the plantar direction, and rotated laterally decreasing the first–second intermetatarsal angle to 5 degrees. Results The mean AOFAS score was 54.1 ± 2.8 points at pre-operation and 92.8 ± 4.8 points at the most recent follow-up (P < 0.0001). Significant improvement was seen between the hallux valgus angle (P < 0.0001), first–second intermetatarsal angle (P < 0.0001), first–fifth intermetatarsal angle (P < 0.0001), talar pitch (P = 0.0032), and calcaneal plantar angle (P = 0.0327) before surgery and at one year after surgery. The average improvement of the talar pitch and calcaneal plantar angle was 2.6 ± 1.4 and 2.4 ± 1.5 degrees, respectively. Conclusion This study suggest that proximal oblique-domed osteotomy of the metatarsal as a surgical procedure for the treatment of moderate or severe hallux valgus with flat foot can be recommended to correct the longitudinal arch of the foot and the first–second intermetatarsal angle.     

足部动脉系统解剖学研究与以跖底动脉为蒂足部组织游离移植术

目的寻求一种更为安全、有效的足部组织游离移植再造拇、手指及关节功能的新方法,进一步提高手术成功率。方法对足部跖底与跖背动脉系统进行显微解剖学研究。设计并应用逆行游离、吻合跖底动脉的足部组织游离移植术治疗76例拇、手指及手部关节缺损患者,其中第二足趾移植58例,第二足趾复合组织移植4例,近侧趾间关节移植8例,(?)甲瓣移植6例。分析总结其疗效。结果第一跖底动脉解剖恒定,到第二足趾的分支粗于第一跖背动脉。75例患者全部成活,移植部位外观良好,功能明显改进,总成活率为98．7%。另1例行第二足趾游离移植再造拇指术患者因顽固性动脉痉挛而改用锁骨下皮管包埋。结论应用逆行游离跖底动脉为蒂的足部组织游离移植术可以克服其它方法存在的血管解剖变异较大、操作复杂、费时等不足,提高了手术效率和成功率。     

Effects of the Lapidus Arthrodesis and Chevron Bunionectomy on Plantar Forefoot Pressures

Hallux valgus with or without first ray insufficiency has been strongly implicated as a contributing factor in lesser metatarsal overload. The principle goals of a bunionectomy are to relieve the pain, correct the deformity, and restore first metatarsophalangeal joint congruity. Until now, little evidence has been available to assess the effects of bunionectomy procedures on forefoot pressure. The primary aim of the present prospective study was to evaluate the preoperative and postoperative plantar pressures after 2 specific bunionectomies: the chevron bunionectomy and Lapidus arthrodesis. A total of 68 subjects, 34 in each group, were included for radiographic and pedographic evaluation. Both procedures demonstrated radiographic improvements in the mean intermetatarsal and hallux abductus angles. The mean hallux plantar pressure decreased significantly in both procedure groups (p < .001). However, Lapidus group exhibited an increase in the mean fifth metatarsal head plantar pressure (p = .008) and pressure under the fifth metatarsal as a percentage of the total forefoot pressure (p = .01). Furthermore, the pressure under the second metatarsal as a percentage of the total forefoot pressure decreased significantly (p = .01). This study suggests that the Lapidus arthrodesis and chevron bunionectomy both provide correction for hallux valgus deformity, but when comparing forefoot load sharing pressures, the Lapidus arthrodesis appeared to have greater influence on the load sharing distribution of forefoot pressure than did the bunionectomy employing the chevron osteotomy.     

Plantar pressures and relative lesser metatarsal lengths in older people with and without forefoot pain

Forefoot pain is a common problem in older people. We determined whether plantar pressures during gait and the relative lengths of the lesser metatarsals differ between older people with and without plantar forefoot pain. Dynamic plantar pressure assessment during walking was undertaken using the Tekscan MatScan® system in 118 community‐dwelling older people (44 males and 74 females), mean age 74 (standard deviation = 5.9) years, 43 (36%) of whom reported current or previous plantar forefoot pain. The relative lengths of metatarsals 1–5 were determined from weightbearing X‐rays. Participants with current or previous plantar forefoot pain exhibited significantly (p = 0.032) greater peak plantar pressure under metatarsal heads 3–5 (1.93 ± 0.41 kg/cm² vs. 1.74 ± 0.48 kg/cm²). However, no differences were found in relative metatarsal lengths between the groups. These findings indicate that older people with forefoot pain generate higher peak plantar pressures under the lateral metatarsal heads when walking, but do not exhibit relatively longer lesser metatarsals. Other factors may be responsible for the observed pressure increase, such as reduced range of motion of the metatarsophalangeal joints and increased stiffness of plantar soft tissues. © 2012 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 31: 427–433, 2013     

Effect of first metatarsal shortening and dorsiflexion osteotomies on forefoot plantar pressure in a cadaver model

BACKGROUND: Metatarsalgia of the second ray is a common problem associated with disorders of the first metatarsal. It also occurs after the operative treatment of those disorders. Plantar pressure changes from alteration of the static and dynamic structure of the forefoot may be associated with this condition. This study evaluated changes in plantar forefoot pressure especially under the second metatarsal head after three operative procedures on the first ray. METHODS: Each of 12 cadaver foot specimens was cyclically loaded on the servohydraulic MTS Mini Bionix test frame (MTS Systems Corp., Eden Prairie, MN) with traction on the Achilles tendon. Plantar forefoot pressure was measured by the F-scan system (Tekscan, Inc., S. Boston, MA) with the foot intact, after a first metatarsal base dorsal closing-wedge osteotomy with 5-mm base length to simulate dorsal malunion, and after 5-mm and 10-mm metatarsal shortening procedures. Paired Student t-test analysis was used to compare data for the intact foot with data after each intervention. One form of Bonferroni's correction was done to establish a new alpha level to tighten the analysis and to compensate for multiple paired Student t-tests. The significance level was calculated to be 0.016 based on an original alpha level of 0.05. RESULTS: As compared with the intact foot, all three procedures on the first metatarsal resulted in significant decreases in plantar pressure under the first metatarsal head (p < 0.016). Plantar pressure under the second metatarsal head increased significantly as compared with the intact foot (p < 0.016) after all three procedures. Pressures under the third-fourth metatarsal heads increased significantly compared with the intact foot after the 5-mm and 10-mm shortenings (p < 0.016). Plantar pressure under the fifth metatarsal did not change significantly after any of the three procedures. CONCLUSIONS: Dorsiflexion osteotomy and shortening of the first metatarsal are associated with significant forefoot plantar pressure changes in a cadaver model.     

Six first metatarsal shaft osteotomies: mechanical and immobilization comparisons

Because malunion (usually with dorsal elevation of the first metatarsal) has been reported after the treatment of severe hallux valgus deformities by proximal osteotomies, the current study was designed to compare the sagittal stability of six different metatarsal shaft osteotomies: the proximal crescentic, proximal chevron, Mau, Scarf, Ludloff, and biplanar closing wedge osteotomies. A plate was used in the biplanar closing wedge osteotomy; all others used screws for fixation. Ten fresh-frozen, human anatomic lower extremity specimens were used for each osteotomy. Failure loads were measured as units of force (newtons) and converted to pressure (kilopascals). Then the F-Scan system, which uses a thin insole to measure plantar pressure, was used to evaluate the pressure under the first metatarsal of seven volunteers using four types of shoes. According to the results, in patients with normal bone stock who are compliant, any of the four shoe types tested may be used after a Ludloff, Scarf, biplanar wedge (plantar screw fixation), or Mau osteotomy, but the wedge-based shoe should be used after a proximal crescentic or chevron osteotomy or for patients with severe osteopenic bone.     

Effect of increasing distal medial closing wedge metatarsal osteotomies on the distal metatarsal articular angle

The recognition, definition, and management of the congruent hallux valgus deformity continue to evolve. To correct the skeletal deformity and maintain joint congruity, many authors have emphasized the importance of extra-articular procedures. One such procedure is a distal medial closing wedge osteotomy of the first metatarsal. Unfortunately, there are few guidelines to help determine the pre- and intraoperative size of the medial wedge to obtain the desired correction of the distal metatarsal articular angle (DMAA). The purpose of this study was to quantify the effects of increasing distal medial closing wedge osteotomies on the DMAA in an in vitro cadaver model. In this study, a closing wedge osteotomy was performed 2 cm proximal to the articular surface, removing wedges measuring 2 mm, 4 mm, and 6 mm in width. The mean preoperative DMAA was 8.5 degrees, and the mean postoperative DMAAs after 2-mm, 4-mm, and 6-mm closing wedge osteotomies were -2.6 degrees, -10.2 degrees, and -20.2 degrees, respectively. The data showed that for every 1 mm of closing wedge osteotomy, the DMAA decreased by 4.7 degrees +/- 0.6 degrees. These results can be used for pre- and intraoperative planning when surgically correcting a congruent hallux valgus deformity with a distal medial closing wedge osteotomy of the first metatarsal. Additional information obtained from this cadaver study includes (1) increased shortening of the first metatarsal and (2) incongruity produced at the joint after the medial-based osteotomy. The amount of shortening of the first metatarsal correlated directly with the size of the medial-based wedge. The second point indicates that a lateral soft-tissue release may still be required when using this method of reorienting the DMAA.     

Osteotomies of the fifth metatarsal.

Although the literature is limited primarily to retrospective small case series of the operative technique of fifth metatarsal osteotomies with a short follow-up, some important information can be learned. Stabilization of the osteotomy with Kirschner wire fixation appears to decrease dorsal displacement of the distal fragment and distal osteotomies; this leads to decreased incidence of transfer metatarsalgia. Kirschner wire fixation is advocated. The proximal chevron osteotomy of the fifth metatarsal, although stable, has a 20% delayed union rate, most likely resulting from the unique vascular anatomy in this region. The radiographic and clinical results appear to be compatible between distal and proximal osteotomies. Based on this information, primary use of a proximal osteotomy technique is not recommended. The oblique diaphyseal osteotomy technique requires an incision for the osteotomy as well as a distal incision at the metatarsophalangeal joint for correction of this joint. Hardware removal was performed in most patients, and the complications included two cases of delayed union. Time to healing was reported to be 8 weeks, 1.5 times the reported time to healing in distal chevron osteotomies. A significant radiographic correction was noted with the oblique diaphyseal osteotomy; however, radiographic measurements can be altered with foot position and lack of x-ray standardization and technique. Kitaoka et al found no correlation with the degree of radiographic correction and post-operative clinical symptoms. The authors agree with Kitaoka et al that the oblique diaphyseal osteotomy should be reserved for patients who fail an initial distal osteotomy technique. Distal oblique osteotomies appear to have less stability and more complications with malunion, transfer metatarsalgia, and delayed union and should be abandoned for a more stable chevron technique. The distal chevron osteotomy has a small incidence of transfer metatarsalgia; however, it appears to improve the clinical radiographic appearance of [table: see text] the foot with a shortened time to healing (4 to 6 weeks). A biplanar technique can be employed with a distal chevron osteotomy to improve plantar callosity symptoms. More studies are needed to examine critically patient outcomes with uniplanar and biplanar techniques using the distal chevron osteotomy.     

The Reverdin-Isham procedure for the correction of hallux abducto valgus. A distal metatarsal osteotomy procedure

The Reverdin-Isham Procedure is a distal metatarsal osteotomy procedure that has stood the test of time and has revolutionized the correction of simple to severe hallux abducto valgus deformities. This procedure, a modification of the classic Reverdin bunionectomy, modifies the osteotomy cut of Reverdin by performing a medial wedge osteotomy through the head of the first metatarsal. In this modification, the osteotomy is performed at an oblique angle from dorsal distal to plantar proximal through the head of the first metatarsal, preserving the entire articular surface of the first metatarsal head. The result of this osteotomy places the articular surface of the first metatarsal into alignment with the shaft of the first metatarsal, thereby correcting the structural deformity of hallux abducto valgus at the first MPJ. This modification, using the advances of minimal incision surgery, is a procedure that is highly successful, permits immediate ambulation, causes minimal disability, allows early return to productive activities, and is cost effective.     

The Ludloff metatarsal osteotomy: guidelines for optimal correction based on a geometric analysis conducted on a sawbone model

Ideally, osteotomy for hallux valgus deformities corrects varus angle and pronation, while minimizing elevation, depression, and shortening. We used a serial linkage tracking device to evaluate five variations of the Ludloff osteotomy, a stable proximal metatarsal osteotomy that incorporates an oblique dorsal to plantar cut and a lateral swing or pivoting correction of the dorsal fragment. A neutral osteotomy (perpendicular to the sagittal plane) yielded the greatest correction (14 degrees) but with shortening (average, 2.85 mm), elevation (average, 1.36 mm), and additional pronation (average, 1.88 degrees). The same osteotomy angled 10 degrees plantarly with 8 degrees of correction produced an average of 1.57 degrees of supination, 1.22 mm of depression and, 0.54 mm of shortening. Additional plantar inclination (20 degrees) and angular correction (16 degrees) yielded increased depression, supination, and shortening. The current findings provide guidelines to achieve the desired correction and rotation and suggest that optimal results can be obtained by performing this osteotomy angled 10 degrees plantarly with a correction of 8 degrees to 16 degrees.     

Planning tool for first metatarsal length in hallux valgus surgery

BackgroundThe precise planning of metatarsal (MT) I length in hallux valgus surgery is important. However, currently no tool exists which allows the surgeon to reliably predict this parameter.Methods30 virtual 3-dimensional hallux valgus surgeries were performed on varied deformation models based on cadaveric feet scans. The shortening of the first ray during distal metatarsal I osteotomy for different osteotomy angles were measured. An algebraic 2-dimensional calculation was done and compared to the results obtained from the 3-dimensional models.ResultsInadvertent shortening of the first metatarsal bone can be as much as 8 mm depending on the amount of intermetatarsal angle (IMA) correction and osteotomy angle. Comparison of the 3 dimensional simulations and the 2 dimensional model resulted in a very strong correlation (R > 0.99 p < 0.00001). Based on our findings an anterior pointing osteotomy of approximately 10° is necessary to restore the length in distal metatarsal I hallux valgus surgery.ConclusionA slight misdirection of the osteotomy plane in distal hallux valgus surgery may result in relevant unwanted alterations in first metatarsal bone length and triangulation by eye is insufficient in this complex geometrical situation without appropriate planning. The present study provides surgeons a practical tool to plan and control the change of first metatarsal length during hallux valgus procedure through exact orientation of the osteotomy angle. If no alteration of length is intended, it may be generalized that an anterior direction of the cut relative to the second metatarsal bone will preserve the length of the first metatarsal bone.     

Distances from the deep plantar arch to the lesser metatarsals at risk during osteotomy: a fresh cadaveric study

Background

The deep plantar arch is formed by anastomosis of the lateral and deep plantar arteries. Osteotomy of the lesser metatarsals is often used to treat metatarsalgia and forefoot deformity. Although it is known that some blood vessels supplying the lesser metatarsals are prone to damage during osteotomy, there is little information on the distances between the deep plantar arch and the three lesser metatarsals. The aims of this study were to identify the distances between the deep plantar arch and the lesser metatarsals and to determine how osteotomy could damage the arch.

Methods

Enhanced computed tomography scans of 20 fresh cadaveric feet (male, n?=?10; female, n?=?10; mean age 78.6 years at the time of death) were assessed. The specimens were injected with barium via the external iliac artery, and the distance from the deep plantar arch to each lesser metatarsal was measured on axial and sagittal images.

Results

The shortest distances from the deep plantar arch to the second, third, and fourth metatarsals in the axial plane were 0.5, 2.2, and 2.8 mm, respectively. The shortest distances from the distal epiphysis to a line passing through the deep plantar arch perpendicular to the longitudinal axis of the lesser metatarsal in the sagittal plane were 47.0, 45.7, and 46.4 mm, respectively, and those from the tarsometatarsal joint were 23.0, 21.0, and 18.6 mm. The deep plantar arch ran at the level of the middle third, within the proximal portion of this third in 11/20 (55.0%), 7/20 (35.0%), and 5/16 (31.2%) specimens, respectively, and at the level of the proximal third in 9/20 (45.0%), 13/20 (65.0%), and 11/16 (68.8%).

Conclusions

Overpenetration into the medial and plantar aspect of the second metatarsal or the proximal and plantar aspect of the fourth metatarsal during shaft or proximal osteotomy could easily damage the deep plantar arch. Shaft or proximal osteotomy approximately 45–47 mm proximal to the distal epiphysis or 18–23 mm distal to the tarsometatarsal joint on the plantar aspect could interrupt blood flow in the deep plantar arch.

     

Blood supply to the first metatarsal head and vessels at risk with a chevron osteotomy

BACKGROUND: Chevron osteotomy, a commonly performed procedure for the treatment of hallux valgus, results in osteonecrosis of the first metatarsal head in 0% to 20% of cases. The aim of this study was to map out the arrangement of the vascular supply to the first metatarsal head and its relationship to the limbs of the chevron osteotomy. METHODS: Ten cadaveric lower limbs were injected with an India ink-latex mixture, and the feet were dissected to assess the blood supply to the first metatarsal head. The dissection was carried out by tracing the branches of the dorsalis pedis and posterior tibial vessels. A distal chevron osteotomy was mapped, with the limbs of the osteotomy set at an angle of 60 degrees from the geometric center of the first metatarsal head. The relationship of the limbs of the osteotomy to the blood vessels was recorded. RESULTS: The first metatarsal head was found to be supplied by branches from the first dorsal metatarsal, first plantar metatarsal, and medial plantar arteries. The first dorsal metatarsal artery was the dominant vessel among the three arteries in eight specimens. All of the vessels formed a plexus at the plantar-lateral aspect of the metatarsal neck, just proximal to the capsular attachment, with a varying number of branches from the plexus then entering the metatarsal head. The plantar limb of the proposed chevron cuts exited through this plexus of vessels in all specimens. Contrary to the widely held view, only minor vascular branches could be found entering the dorsal aspect of the neck. CONCLUSIONS: The identification of the plantar-lateral corner of the metatarsal neck as the major site of vascular ingress into the first metatarsal head suggests that constructing the chevron osteotomy with a long plantar limb exiting well proximal to the capsular attachment may decrease the postoperative prevalence of osteonecrosis of the first metatarsal head.     

双平面截骨术治疗合并跖骨远端关节面角增大的重度■外翻

目的总结双平面截骨术治疗合并跖骨远端关节面角(distal metatarsal articular angle,DMAA)增大的重度[足母]外翻疗效。方法回顾性分析2014年6月-2017年12月收治并获完整随访的64例(94足)合并DMAA增大的重度[足母]外翻患者临床资料。患者均接受双平面截骨术(跖骨远端Reverdin截骨术+跖骨近端开放楔形截骨术)联合Akin截骨术及软组织手术。男10例(15足),女54例(79足);年龄26~66岁,平均44.5岁。单侧34例,双侧30例。参照美国矫形足踝协会(AOFAS)Maryland跖趾关节评分系统评分为(54.3±7.4)分,疼痛视觉模拟评分(VAS)为(6.0±2.0)分。比较手术前后AOFAS Maryland跖趾关节评分系统评分及VAS评分,以及[足母]外翻角(hallux valgus angle,HVA)、第1-2跖骨间角(first-second intermetatarsal angle,1-2IMA)、DMAA、第1跖骨长度(first metatarsal length,FML)。结果术后切口均Ⅰ期愈合。患者均获随访,随访时间12~15个月,平均13.2个月。4足发生并发症,其中[足母]僵硬、内侧切口边缘皮肤感觉麻木、转移性跖痛、第1跖骨头坏死各1足。术后1年AOFAS Maryland跖趾关节评分为(89.2±7.4)分,与术前比较差异有统计学意义(t=18.427,P=0.000);其中优78足、良12足、中3足、差1足,优良率为95.7%。VAS评分为(1.5±2.0)分,较术前明显改善(t=10.238,P=0.000)。X线片复查显示术后3个月截骨均达骨性愈合。术后6个月及1年HVA、1-2IMA、DMAA与术前比较,差异均有统计学意义(P<0.05);术后1年FML与术前比较,差异无统计学意义(t=0.136,P=0.863)。结论双平面截骨术可以显著改善合并DMAA增大的重度[足母]外翻患者临床症状以及影像学参数,术后并发症少。     

拇外翻足并发第2跖骨头下疼痛的相关因素研究

目的:通过对拇外翻足足弓的X线指标与足底压力指标的检测,分析拇趾外翻角的变化与足弓X线测量指标变化及足底压力变化的相关性,探讨拇外翻足并发第2跖骨头下疼痛影响因素。方法:采用回顾性研究方法,观察自2012年1月至2013年6月治疗的254例(477足)拇外翻患者病历资料,记录患者第2跖骨头下疼痛及年龄的情况,把所有拇外翻足按并发第2跖骨头下疼痛的有无分为两组(疼痛组和无痛组),分别测量各组负重位拇外翻足拇趾外翻角(hallux abductor valgus angle,HAVA),第1、2跖骨间角(the inter-metatarsal angle between the first and second metatarsals,IMA1-2),第1、5跖骨间角(the inter-metatarsal angle between the first and fifth metatarsals,IMA1-5),内弓顶角、前弓顶角及第1、2跖骨头的相对长度,检测步态中第2跖骨头下峰压强、冲量、触地时间百分比等压力的情况。运用相关性分析及Logistic回归分析方法,探讨拇外翻足并发第2跖骨头下疼痛的影响因素。结果:Spearman相关性分析结果示HAVA分别与各测量指标的IMA1-2、IMA1-5、内弓顶角、前弓顶角、第2跖骨触地时间百分比呈相关性(P0.05,r=0.647、0.553、0.127、-0.165、0.158)。Logistic回归分析结果示并发第2跖骨头下疼痛的影响因素为HAVA、第2跖骨相对长度、第2跖骨头触地时间百分比(P0.05,ORj=1.030,1.069,1.060)。结论:拇外翻角的增大导致了拇外翻足足弓塌陷,使步态中第2跖骨头负重的时间延长,从而导致了第2跖头下疼痛的发生。     

Distal Oblique Metatarsal Osteotomy for Hallux Valgus Deformity: A Clinical Analysis

We compared the outcomes of the distal oblique metatarsal (DOM) osteotomy, which is parallel to the articulation surface of the proximal phalanx, with those of the chevron osteotomy and evaluated whether displacement and shortening of the first metatarsal have any effect on the incidence of metatarsalgia and patient satisfaction. Patients treated with the DOM osteotomy (n = 30) or distal chevron osteotomy (n = 31) were evaluated retrospectively. The chevron and DOM osteotomies both provided significant improvement in the first intermetatarsal angle (p < .001), hallux valgus angle (p < .001), distal metatarsal articular angle (p < .001), range of first metatarsophalangeal joint motion (p < .001), American Orthopaedic Foot and Ankle Society score (p < .001), and sesamoid position (p < .001), without any significant differences between the 2 groups. Patient satisfaction and metatarsalgia also were not different between the study groups. The DOM osteotomy group had higher plantar displacement (0.1 ± 0.1 mm versus 1.0 ± 0.1 mm; p < .001) and absolute shortening of the first metatarsal (1.0 ± 0.4 mm versus 6.8 ± 1.0 mm; p < .001). In conclusion, the DOM osteotomy is an alternative treatment method for mild and moderate hallux valgus.