Metatarsalgia: distal metatarsal osteotomies

Metatarsalgia is a common pathologic entity. It refers to pain at the MTP joints. Pain in the foot unrelated to the MTP joints (such as Morton’s neuroma) must be distinguished from those disorders, which lead to abnormal pressure distribution, reactive calluses, and pain. Initial treatment options for metatarsalgia include modifications of shoe wear, metatarsal pads, and custom-made orthoses. If conservative treatment fails, operative reconstructive procedures in terms of metatarsal osteotomies should be considered. Lesser metatarsal osteotomy is an effective and well-accepted method for the management of metatarsalgia. The main purpose of these osteotomies is to decrease prominence of the symptomatic metatarsal head. The distal metatarsal oblique osteotomy (Weil osteotomy) with its modification represents the best evaluated distal metatarsal osteotomy in terms of outcome studies and biomechanical analysis. The role of the Weil osteotomy in metatarsalgia owing to a subluxed or dislocated MTP joint is to bring the metatarsal head proximal to the callus and to provide axial decompression of the toe to correct the deformity contributing to metatarsalgia.     

Simultaneous radial closing wedge and ulnar shortening osteotomies for distal radius malunion

PURPOSE: Closing wedge osteotomies are an attractive treatment option for distal radius malunion in patients with osteopenia; however, they require an ulnar head resection to accommodate closure of corrective osteotomy and to address the issue of ulnocarpal abutment. The literature contains little information on concomitant ulnar shortening osteotomy despite a physiologic solution. We report the functional and radiographic outcomes of 5 patients treated for symptomatic distal radius malunion with simultaneous radial closing wedge and ulnar shortening osteotomies. METHODS: All 5 patients were women aged 52 to 69 years (average, 61 years). Four patients had extra-articular radius fractures with dorsal angulation (20-22 degrees ) and shortening (3-7/mm); the other had the fracture with volar angulation (24 degrees ) and shortening (11 mm). Through a volar approach an appropriate amount of bone wedge was removed from the distal radius. A small volar T-plate was used to secure the osteotomized bone fragment. Six to 11 mm of ulnar shortening osteotomy was performed by using transverse osteotomy and compression plating technique with an AO compression device. RESULTS: In all 5 wrists healing of radial and ulnar osteotomies occurred less than 3 months after surgery. There were no postsurgical complications. Postsurgical radiographs showed that the volar tilt angle of the radius was reduced to normal range (range, 8-15 degrees ) in all wrists. The ulnar variance was 0 mm in 4 wrists and 2 mm in 1 wrist. There were significant improvements in pain, function, and range of motion at an average follow-up evaluation of 17 months. The average grip strength as a percentage of the opposite side improved from 30% before to 73% after surgery. CONCLUSIONS: This study showed that closing wedge osteotomy of the radius concomitant with ulnar shortening osteotomy is technically and functionally adequate. Our procedure is indicated for patients with osteopenia for whom opening wedge osteotomy of the radius is inadequate.     

Variation of the distal metatarsal articular angle with axial rotation and inclination of the first metatarsal

BACKGROUND: The distal metatarsal articular angle (DMAA) is a radiographic measure of the orientation of the first metatarsal articular surface. There is debate with regards to the accuracy, reproducibility, and validity of measurement of the DMAA in the literature. This study aimed to test the validity of the measurement of the DMAA from standard radiographs, to explore the trigonometric relationship of the first metatarsal rotation and the DMAA, and to assess interobserver reliability. METHODS: Thirty-four separate dry cadaver first metatarsal bones were mounted onto a customized light-box-protractor, allowing controlled incremental changes in rotation and inclination. A series of 39 digital photographs were taken of each metatarsal in 5-degree increments of rotation between 30 degrees supination and 30 degrees pronation at 10, 20 and 30 degrees of inclination. Three reviewers performed blinded DMAA measurements from each photographic image; the data were collated for statistical analysis. The data were analysed using a mixed effects linear model comparing the DMAA with rotation of the first metatarsal. RESULTS: A strong statistically significant trend of increasing score with increasing pronation of the metatarsal was observed, the relationship was approximately linear. There was a strong effect of inclination, but the strength of this varied with rotation and was amplified at higher inclinations. Interobserver error was noted in line with other studies, but even allowing for this interobserver error, the linear relationship was maintained. CONCLUSIONS: This study showed that the DMAA varies significantly in a linear pattern with axial rotation of the first metatarsal. Inclination of the first metatarsal also affects the magnitude of the angle. This study does not refute the DMAA as an entity but does confirm the inaccuracy of extrapolating the DMAA from plain anteroposterior radiographs.     

Treatment of hallux valgus with an increased distal metatarsal articular angle: evaluation of double and triple first ray osteotomies

During a 12-year period in which 878 hallux valgus corrections were performed, 18 patients (21 feet) with symptomatic hallux valgus deformity and an increased distal metatarsal articular angle (DMAA) underwent periarticular osteotomies (double or triple first ray osteotomies). They were studied retrospectively at an average follow-up of 33 months. The surgical technique comprised a closing wedge distal first metatarsal osteotomy combined with either a proximal first metatarsal osteotomy or an opening wedge cuneiform osteotomy (double osteotomy). When a phalangeal osteotomy was added, the procedure was termed a "triple osteotomy." The average age of the patients at the time of surgery was 26 years. At final follow-up, the average hallux valgus correction measured 23 degrees and the average 1-2 intermetatarsal angle correction was 9 degrees. The DMAA averaged 23 degrees preoperatively and was corrected to an average of 9 degrees postoperatively. One patient developed a postoperative hallux varus deformity, and one patient developed a malunion, both of which required a second surgery. A hallux valgus deformity with an increased DMAA can be successfully treated with multiple first ray osteotomies that maintain articular congruity of the first metatarsophalangeal joint.     

Comparison of oblique closing base wedge osteotomies of the first metatarsal: stripping versus nonstripping of the periosteum

The authors present a study comparing two methods of performing the oblique closing base wedge osteotomy of the first metatarsal for correction of hallux abducto valgus deformity. In one group, the periosteum was stripped from the metatarsal prior to performing the osteotomy, and in the other group, the osteotomy was performed through the periosteum. Sixty-five osteotomies are included in the study. This article discusses the closing base wedge osteotomy, fracture healing and the role of the periosteum, the blood supply to the first metatarsal, and the effects of periosteal stripping. Also included is a presentation of the surgical technique used, a statistical review of the procedures performed, a critical discussion summarizing the results, and a discussion of the postoperative complications encountered.     

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。     

Intra- and inter-observer reliability of the distal metatarsal articular angle in adult hallux valgus

There is some uncertainty as to whether the distal metatarsal articular angle (DMAA) is a real entity or just radiographic artifact and whether it can be reliably measured. If it is intrinsic to the bone, it should not change with bone position. If it is clinically useful, it should be reproducible. Pre-operative and post-operative radiographs of 32 patients undergoing a proximal bony procedure of the first ray were evaluated independently by three foot and ankle specialists in order to determine the intra and inter-observer reliability of the distal metatarsal articular angle (DMAA). In addition, the hallux valgus angle (HVA), intermetatarsal angle (IMA) and joint congruency/subluxation were determined. We used ANOVA (Scheffe's F-test) to determine reliability of the angular measurements; a p value of less than 0.05 indicates poor reliability and a p value of greater than 0.05 indicates reliability. Intra-observer reliability was good for all angular measurements (HVA, IMA, DMAA pre-op, and DMAA post-op) with p values ranging from 0.33 to 0.95. Inter-observer reliability of the HVA and IMA was good (p=0.63 and p=0.32). Inter-observer reliability of the pre-op DMAA approached statistically poor reliability (p=0.09) and the post-op DMAA reliability was poor (p=0.002). The DMAA reduced after the proximal procedure as measured by all observers, and averaged a reduction of 3.9 degrees. Weighted kappa analysis also revealed that there was poor agreement in the determination of congruency and subluxation (Kappa statistic ranged from 0.07 to 0.19). This study suggests that there may be limited value in the DMAA as a clinical measure as it varies with examiner and with the hallux valgus angle.     

Percutaneous sagittal plane closing wedge osteotomy of the first metatarsal

Osteotomy of the first metatarsal in the sagittal plane is useful in correction of numerous deformity of the foot. Plantarflexion osteotomy of the first metatarsal can be used to treat hallux rigidus, hallux limitus, forefoot varus in flatfoot deformity and iatrogenic metatarsus primus elevates. Dorsiflexion osteotomy of the first metatarsal is an important component in surgical correction of pes cavus. It is also indicated in recalcitrant diabetic neuropathic ulcers at the first metatarsal head. We described a minimally invasive technique of sagittal plane corrective osteotomy of the first metatarsal, which can be either a plantarflexion or dorsiflexion one.     

Distal femoral varus osteotomy: unloading the lateral compartment: long-term follow-up of 45 medial closing wedge osteotomies

Distal femoral medial closing wedge osteotomy is useful for mechanical axis realignment to unload the lateral compartment of the valgus knee. The primary indication for unloading the lateral compartment is lateral unicompartmental osteoarthritis. Alternative treatment options include lateral unicompartment or total knee arthroplasty (TKA). Prerequisites for the osteotomy include a 90° arc of motion, age younger than 60 years, and an active patient capable of an extensive period of rehabilitation. Surgery is carried out through a midline skin incision and uses a subvastus approach. The medial femoral closing wedge osteotomy is fixed with a 90° dynamic compression blade plate. A critical technical point is the need to insert the blade plate parallel to the joint line. The right angle plate corrects the tibialfemoral angle to 0°. A benefit of the closing wedge over an opening wedge osteotomy is reduced risk of nonunion. Survivorship and functional outcome of 41 patients with 45 distal femoral varus osteotomies at a mean follow-up of 13.3 years were retrospectively analyzed. Survivorship at 10, 15, and 20 years was 90%, 79%, and 21.5% respectively. Mean Modified Knee Society Score was 36.1 preoperatively, 74.4 at 1-year postoperatively, and 60.5 at last follow-up. Distal femoral varus osteotomy is effective at unloading the lateral compartment in unicompartmental arthritis in the valgus knee. It may be indicated in the young, high activity demand, and overweight patient. By 20 years after the osteotomy most patients require conversion to TKA.     

First metatarsal closing base wedge osteotomy using real-time fluoroscopy

A minimal incision surgery approach to metatarsus primus adductus is presented. The percutaneous closing base wedge osteotomy is performed using real-time intraoperative fluoroscopy. The advantages and disadvantages of this minimal incision surgical procedure are discussed.     

The relationship between the distal metatarsal articular angle and intersesamoidal crista: An osteological study

BackgroundAs hallux valgus (HV) progresses, the first metatarsal drifts medially and the subsequent lateral drift of the sesamoids results in intersesamoidal crista erosion. This study aimed to provide a novel method of assessing crista erosion and determine if there is a relationship between that erosion and an increase in the distal metatarsal articular angle (DMAA).MethodsThe DMAA and size of the intersesamoidal crista was measured on the first metatarsals of 120 adult modern human individuals. There was an equitable spread of both sexes, a wide age range (18–88 years), from three South African population groups (Zulu, Sotho, “European”). The following non-metric features were observed: intersesamoidal crista appearance, metatarsal head shape, and first intermetatarsal facet. Correlation tests, t-tests and Analyses of Variance (ANOVA) were used to determine relationships between variables.ResultsThe Pearson correlation test showed no significant correlation between the DMAA and crista ratio (r = 0.092, p = 0.154, α = 0.05). DMAA: there was a significant difference between sides (p = 0.009), right side larger; there was a significant difference between Zulu and “European” samples (p = 0.036) but not between “Europeans” and Sotho (p = 0.270); and there was a slight positive correlation with an increase in age. Crista: there was a significant difference between the sexes (p = 0.044), with females having less erosion.ConclusionsThere is no significant relationship between the DMAA and crista erosion. Severe cartilaginous erosion is present before osteological changes occur, and the unexpected result may be reflected in skeletal specimens in which no cartilaginous changes can be observed. A novel, experimental method of assessing HV in modern human skeletal material is proposed.     

Percutaneous dorsal closing wedge osteotomy of the metatarsal neck in management of metatarsalgia

IntroductionMetatarsalgia can be caused by plantarflexion of a central metatarsal or discrepancies in the metatarsals’ length. Nonsurgical management is usually sufficient to achieve satisfactory results. For those recalcitrant cases, metatarsal osteotomy is needed to relieve the pain. We describe a technique of percutaneous dorsal closing wedge osteotomy of the metatarsal to manage the recalcitrant metatarsalgia. A case series was reviewed retrospectively.Materials and methodsFrom March 2010 to March 2013, percutaneous dorsal closing wedge osteotomy of the metatarsal neck has been performed in 33 patients. Thirty six feet with 63 metatarsals were operated on. Thirty two second metatarsals, 22 third metatarsals, 5 fourth metatarsals and 4 fifth metatarsals were operated on.ResultsAll the osteotomy sites healed up without any transverse plane deformity. The painful callosities subsided except in one operated metatarsal. Recurrence of painful callosities occurred in 2 operated metatarsals. Transfer metatarsalgia occurred in 2 feet. Floating toe deformity occurred in 2 operated rays. There was no nerve injury noted. Two patients had delayed wound healing with serous discharge and the wounds were eventually healed up with wound dressing.ConclusionPercutaneous dorsal closing wedge osteotomy of the metatarsal neck is an effective and safe surgical treatment of recalcitrant metatarsalgia.     

Basal medial opening wedge first metatarsal osteotomy stabilized with a low profile wedge plate

Twenty patients underwent 25 basal medial opening wedge osteotomies of the first metatarsal stabilized using a low-profile wedge plate in combination with a distal soft tissue release, distal metatarsal osteotomy and Akin osteotomy as required for correction of a hallux valgus deformity. The mean clinical and radiographic follow-up was 12.2 months. Pre- and post operative radiographs available in 15 cases showed that the median hallux valgus angle (HVA), intermetatarsal angle (IMA) and distal metatarsal articular angle (DMAA) were corrected from 45.5 to 13.1, 17.7 to 9.2 and 243 to 10.0 degrees respectively (p < 0.001). Final radiographic assessment for the whole series showed a median final HVA and IMA of 14.1 and 9.1 respectively. Radiographic union was noted in all but one case which was asymptomatic. One wound infection was treated with oral antibiotics, one hallux varus deformity required soft tissue reconstruction and there was one recurrence. The outcome was reported as good or satisfactory by the patients for 20 of 25 feet. Three patients reported stiffness in the first MTP joint, which improved with joint injection and manipulation. Two plates were removed for prominence. The basal medial opening wedge osteotomy stabilized with a low profile wedge plate was an effective addition for correcting a moderate to severe hallux valgus deformity as part of a double or triple first ray osteotomy.     

Comparative mechanical testing of different geometric designs of distal first metatarsal osteotomies

BACKGROUND: The mechanical behavior of a newly described distal metatarsal osteotomy design in the shape of a reversed "L" was compared with the modified chevron and scarf osteotomies. METHODS: Experiments were performed using full-sized Sawbone models (Sawbones Europe AB, Malm?, Sweden) of the first ray. Three groups consisting of 10 scarf, 10 modified chevron, and 10 reversed L osteotomies were investigated. All distal fragments were displaced 5 mm laterally without angulation. The proximal fragment of each specimen was embedded in an epoxy resin cylinder and positioned at 15 degrees inclination to the ground. The distal fragment was loaded by a dorsally directed vertical force which was applied at the sesamoid location under the metatarsal head. Load and displacement at failure, work to failure, site of failure and contact areas were recorded for each osteotomy. RESULTS: Similar testing results were obtained in the reversed "L" and chevron osteotomies, while the scarf osteotomy needed almost 5 times less work to failure. In nine of 10 reversed "L" osteotomies and in all scarf osteotomies, the site of failure was at the proximal screw insertion site. The contact areas averaged 163 mm(2) for the reversed "L," 116 mm(2) for the chevron, and 270 mm(2) for the scarf osteotomy. CONCLUSIONS: The reversed L osteotomy is a promising design combining the advantages of both the chevron and scarf osteotomies. Further investigations need to be performed to confirm its clinical utility.     

High tibial closing wedge osteotomy for medial compartment osteoarthrosis of knee

Background:

Most patients of symptomatic osteoarthrosis of knee are associated with varus malalignment that is causative or contributory to painful arthrosis. It is rational to correct the malalignment to transfer the functional load to the unaffected or less affected compartment of the knee to relieve symptoms. We report the outcome of a simple technique of high tibial osteotomy in the medial compartment osteoarthrosis of the knee.

Materials and Methods:

Between 1996 and 2004 we performed closing wedge osteotomy in 78 knees in 65 patients. The patients selected for osteotomy were symptomatic essentially due to medial compartment osteoarthrosis associated with moderate genu varum. Of the 19 patients who had bilateral symptomatic disease 11 opted for high tibial osteotomy of their second knee 1-3 years after the first operation. Preoperative grading of osteoarthrosis and postoperative function was assessed using Japanese Orthopaedic Association (JOA) rating scale.

Results:

At a minimum follow-up of 2 years (range 2-9 years) 6-10° of valgus correction at the site of osteotomy was maintained, there was significant relief of pain while walking, negotiating stairs, squatting and sitting cross-legged. Walking distance in all patients improved by two to four times their preoperative distance of 200-400 m. No patient lost any preoperative knee function. The mean JOA scoring improved from preoperative 54 (40-65) to 77 (55-85) at final follow-up.

Conclusion:

Closing wedge high tibial osteotomy performed by our technique can be undertaken in any setup with moderate facilities. Operation related complications are minimal and avoidable. Kirschner wire fixation is least likely to interfere with replacement surgery if it becomes necessary.