Modifications of the Weil osteotomy have no effect on plantar pressure

Previous studies have shown that increasing angulation of the Weil osteotomy produces greater plantar translation of the metatarsal head. Modifications have been proposed to reduce plantar translation. However, there is no evidence that the increased plantar translation with a Weil osteotomy is clinically significant or that these modifications are required. Ten lower extremities consisting of five matched pairs were used to evaluate whether different configurations of the Weil osteotomy altered plantar pressure in a dynamic cadaver model. For each pair, an oblique Weil osteotomy with a 5-mm shift was done on one side and a standard (parallel) Weil osteotomy with a 5-mm shift was done on the matched foot. A 4-mm slice resection and a metatarsal head resection then were done sequentially. Plantar pressures were measured with cyclic loading to 700 N at a frequency of 1 Hz with an F-scan in-shoe sensor on the intact specimens and after each intervention. Increased plantar translation of the metatarsal head with a more oblique Weil osteotomy did not significantly increase plantar pressure, and the 4-mm slice resection did not significantly unload the metatarsal head. Only complete metatarsal head resection significantly unloaded the metatarsal head.     

两种第二趾切取游离移植对供足足底应力影响的生物力学研究

目的 探讨第2足趾切取游离移植对供足足底应力的影响.方法 取6具正常成人新鲜尸体足标本,根据不同状态分3组:完整组(A组)、第2趾截除(保留跖骨头)组(B组)及带部分跖骨的第2趾截除(跖骨远l/3处)组(C组).应用电子万能试验机以2 mm/min的速度从胫骨远端施加轴向压载,加载载荷分别为0、600、1200 N.通过F-Scan足底压力测量系统检测足底应力变化,并对数据进行统计学分析.结果 足底应力随轴向压载的增加而增大.A组(足母)指及5个跖骨头的峰值压强以第2跖骨头最大,600 N垂直载荷时为(37.33±7.34)kPa,1200 N垂直载荷时为(112.33±10.33)kPa.同一载荷下,A组与B组的(足母)指及5个跖骨头的峰值压强差异均无统计学意义(P>0.05).同一载荷下,A组、B组分别与C组比较,(足母)指及5个跖骨头的峰值压强差异均有统计学意义(P<0.05).结论 第2跖骨的完整对足底应力正常分布及维持足弓具有重要意义.保留跖骨头的第2趾切取对供足足底应力分布影响较小,带部分跖骨的第2趾切取可导致供足足底应力的异常分配.     

Plantar pressure and load in cadaver feet after a Weil or chevron osteotomy

BACKGROUND: Since metatarsal osteotomy was first used to treat metatarsalgia in the early twentieth century, many techniques have been described to accomplish the basic aim of reduction of load transmission through the operated metatarsal and reduction of localized high pressure on the plantar surface of the metatarsal. Our study examined two popular distal metatarsal neck osteotomies used for the relief of central metatarsalgia and the biomechanical changes that result from their use in a cadaver forefoot model. METHODS: After applying 445 N (100 lbs) of axially directed force, we measured plantar pressure using the TekScan HR Mat (TekScan, Inc., South Boston, MA) in twelve paired, thawed, fresh-frozen intact cadaver legs, then after either a Weil or chevron osteotomy of the second metatarsal and finally after the addition of the same osteotomy of the third metatarsal. RESULTS: Load in the forefoot was not significantly affected by the Weil osteotomy. A significant increase in load was produced in the first metatarsal region, and significant decreases in load were produced beneath the operated metatarsal heads after the chevron osteotomy. Average pressure in the contact area of the forefoot showed similar trends; however, load and pressure changes occurred independently, owing to the changes in contact area produced by the osteotomies. No significant changes were observed in the nonoperated metatarsal regions. CONCLUSIONS: In this model, the chevron osteotomy more effectively reduced load and plantar pressure in the operated metatarsal regions; however, increases in load and pressure were observed in the first metatarsal region. The increase in pressure without a change in load in region 3 (third metatarsal) after a Weil osteotomy of the third metatarsal was attributed to the creation of a plantar prominence. This study did not show a reduction in load transmission as a result of the Weil osteotomy, which contradicts the proposed mechanism of clinical benefit. An intact first ray likely prevents transfer of load or pressure to adjacent lesser metatarsals with chevron osteotomy.     

正常足与外翻足的足底压力研究

目的　对正常足与外翻足的足底压力进行测量。方法　运用自行研制的足底生物力学测试系统对30 名健康人60 足,45 例外翻患者89 足进行了行走时足底压力的测试。结果　重度外翻组31 足和正常组相比,第一跖骨头下压力明显减低( P< 0.001),第二跖骨头下压力明显增加(P< 0 .05),第三、五跖骨头下压力有增高的趋势。结论　正常人前足第一跖骨头下压力最高,并向外侧递减。重度外翻足前足第一跖骨头下压力明显减低,第二跖骨头下压力明显增高     

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.

     

The effects of a medializing calcaneal osteotomy with and without superior translation on Achilles tendon elongation and plantar foot pressures

BACKGROUND: The medial calcaneal osteotomy (MCO) is a frequently used corrective procedure for posterior tibial tendon (PTT) insufficiency; however, patients often complain of lateral foot pain postoperatively. Published findings have documented the usefulness of MCO in off-loading the plantar surface of the first and second metatarsal heads but with a concomitant increase in peak pressure over the lateral forefoot and heel. Achilles tendon elongation revealed a trend toward shortening of the ventromedial aspect of the tendon. It was then hypothesized that translating the osteotomized posterior aspect of the calcaneus medially and superiorly would reduce lateral forefoot pressure and decrease the amount of lengthening of the Achilles tendon while continuing to relieve medial forefoot pressure. METHODS: Twenty-eight fresh-frozen cadaver legs were axially loaded on a load-frame device to 100 lbs to assess the effects of a 1-cm MCO in conjunction with either 0.5-cm or 1-cm superior translation on plantar foot pressures and Achilles tendon elongation. RESULTS: The 0.5-cm superior translation resulted in a greater off-loading of the first and second metatarsals than the MCO alone with a trend toward decreased pressures in the lateral forefoot. The 1-cm superior translation continued to unload the first and second metatarsals; however, lateral forefoot and midfoot pressures were increased. Achilles tendon lengthening remained unchanged in the cadaver foot model. CONCLUSIONS: Our findings suggest that the addition of a 0.5-cm superior translation to the traditional 1-cm MCO should allow some degree of off-loading of the medial forefoot without increasing lateral forefoot or heel pressures.     

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.     

Lateral column calcaneal lengthening, flexor digitorum longus transfer, and opening wedge medial cuneiform osteotomy for flexible flatfoot: a biomechanical study

BACKGROUND: Lengthening of the lateral column is commonly used for reconstruction of the adult and pediatric flatfoot, but can result in supination of the foot and symptomatic lateral column overload. The addition of a medial cuneiform osteotomy has been used to redistribute forces to the medial column. The combined use of a lateral column lengthening and medial cuneiform osteotomy in a reproducible cadaver flatfoot model was evaluated. METHODS: Twelve cadaver specimens were physiologically loaded and each was evaluated radiographically and pedobarographically in the following conditions: 1) intact, 2) severe flatfoot, 3) lateral column lengthening with simulated flexor digitorum longus transfer, and 4) lateral column lengthening and flexor digitorum longus (FDL) transfer with added medial cuneiform osteotomy. The lateral column lengthening was performed with a 10-mm foam bone wedge through the anterior process of the calcaneus, and the medial cuneiform osteotomy was performed with a dorsally placed 6-mm wedge. RESULTS: Lateral column lengthening with simulated FDL transfer on a severe flatfoot model resulted in a significant change as compared with the flatfoot deformity in three measurements: in lateral talus-first metatarsal angle (-17 to -7 degrees; p<0.001), talonavicular angle (46 to 24 degrees; p<0.001), and medial cuneiform height (16 to 20 mm; p<0.001). Lateral forefoot pressure increased from 24.6 to 33.9 kPa (p<0.001) after these corrections as compared with the flatfoot. Adding a medial cuneiform osteotomy decreased the lateral talar-first metatarsal angle from -7 to -4 degrees, decreased the talonavicular coverage angle from 24 to 20 degrees, and increased the medial cuneiform height from 20 to 25 mm. After added medial cuneiform osteotomy, lateral pressure was significantly different from that of the flatfoot (p=0.01) and was not significantly different from that of the intact foot (p=0.14). Medial forefoot pressure was overcorrected as compared with the intact foot with added medial cuneiform osteotomy. CONCLUSIONS: Lateral column lengthening increased lateral forefoot pressures in a severe flatfoot model. An added medial cuneiform osteotomy provided increased deformity correction and decreased pressure under the lateral forefoot.     

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.     

Plantar pressure analysis in cadaver feet after bony procedures commonly used in the treatment of stage II posterior tibial tendon insufficiency

BACKGROUND: Bony procedures play an essential role in the operative treatment of stage II posterior tibial tendon insufficiency and often substantially alter the loading characteristics of the foot. METHODS: Eight matched pairs of cadaver lower extremities were axially loaded onto a TekScan HR Mat. (TekScan, Inc., South Boston, MA) After intact testing, each specimen had a lateral column lengthening (either a calcaneocuboid distraction arthrodesis [CCDA] or Evans procedure), a medializing calcaneal osteotomy (MCO), and a plantarflexion (Cotton) osteotomy of the medial cuneiform. The measured plantar pressures were divided into three forefoot regions, two midfoot regions, and two hindfoot regions. For each region, average pressure, peak pressure, and contact area data were collected. RESULTS: Despite the fact that both lateral column lengthening procedures resulted in increased lateral forefoot pressures, no significant differences were noted between the CCDA and the Evans procedure. The addition of a MCO did not significantly alter the plantar pressures measured after the lateral column lengthening alone. Although the Cotton osteotomy resulted in increased average pressures within the medial forefoot, a compensatory significant decrease in lateral forefoot pressures was not observed. CONCLUSIONS: The present study demonstrated increased lateral forefoot pressures after a combined lateral column lengthening and MCO and does not support the idea that a Cotton osteotomy significantly reduces loading of the lateral forefoot. CLINICAL RELEVANCE: The incidence of lateral forefoot pain and fifth metatarsal stress fractures subsequent to either lateral column lengthening procedure may not significantly decline after a Cotton osteotomy.     

Comparison of plantar pressure, clinical, and radiographic changes of the forefoot after biplanar Austin osteotomy and triplanar Boc osteotomy in patients with mild hallux valgus

BACKGROUND: Boc's modification of the Austin procedure is a triplane distal osteotomy that achieves shortening and plantarflexion of the first metatarsal with a lateral translation of the metatarsal head. The clinical results and influence of the Austin and Boc osteotomies on plantar pressure have been compared retrospectively. MATERIALS AND METHODS: The patients were divided into two groups: 30 Austin and 30 Boc osteotomies were performed with a mean followup of 37 (range, 29 to 56) months. RESULTS: Sixty patients with mild hallux valgus deformities and central metatarsalgia, took part in the study. Pressure measurements were performed with a Diagnostic Support system footplate. The average postoperative American Orthopaedic Foot and Ankle Society score of the Austin group was 81.9 and 86.4 for the Boc group. The pressure distributions under the fourth and fifth metatarsal head were comparable in both groups (p>0.05). The Austin group showed decreased load bearing under the hallux and the first metatarsal head (p<0.01), consistent with a persistent overloading of the second and third metatarsal head (p>0.05). The Boc group showed decreased weightbearing under the hallux with better load distribution beneath the second and the third metatarsal head (p<0.05). Correlation of the American Orthopaedic Foot and Ankle Society scores and pressure variables confirmed a significant negative correlation with altered hallux and central metatarsal head loading (p<0.01). CONCLUSION: The Boc triplane osteotomy seems to restore more physiologic loading of the forefoot in comparison to the Austin procedure, reducing the incidence of painful callus under the second and third metatarsal head.     

Salvage of the neuropathic foot by using bone resection and tendon balancing: A retrospective review of 10 patients

Medical records were retrospectively reviewed for 10 patients (mean age, 48.7 years) who had a chronic, recurrent neuropathic forefoot ulceration or osteomyelitis in the presence of an abnormal metatarsal parabola. Two patients had multiple lesser metatarsal osteomyelitis, 3 patients had chronic ulceration in the presence of an abnormal metatarsal parabola, and 5 patients had previous lesser ray resection or metatarsal head resection. None of the patients had signs of skin breakdown under the first metatarsal. All of the patients were treated with a combination gastrocnemius recession, peroneus longus to peroneus brevis tendon transfer, and resection of the second through fifth metatarsal heads to decrease plantar forefoot pressure and preserve the first ray without increasing the risk of ulceration under the first metatarsal head. All patients achieved a healed plantigrade foot without ulcer recurrence, transfer callus development, or contralateral foot breakdown at a mean follow-up of 14.2 months. Postsurgical complications consisted of dehiscence of various incision sites on 3 individual patients and one local reaction to antibiotic-impregnated beads. This preliminary study suggests that this combination of reconstructive procedures may provide an alternative method of foot salvage to panmetatarsal resection and transmetatarsal amputation.     

Plantar pressures in the forefoot after lateral column lengthening: a cadaver study comparing the Evans osteotomy and calcaneocuboid fusion

BACKGROUND: Excessive varus alignment of the forefoot after lateral column lengthening has been reported to lead to overloading of the lateral foot. The purpose of this study was to investigate whether there is a difference between the Evans opening wedge calcaneal osteotomy (Evans) and the calcaneocuboid distraction arthrodesis (CCDA) with respect to lateral forefoot loading. METHODS: In each of 12 matched pairs of cadaver feet, plantar pressure measurements of the intact specimens were obtained during simulated foot-flat and early heel-rise phases of gait and again after randomly performing the Evans procedure on one foot and the CCDA on the other foot. Cervical plate fixation was used for immediate stability. RESULTS: Both procedures resulted in statistically significant increased loading of the lateral forefoot and decreased loading of the medial forefoot compared with the preoperative status. The relative increase in lateral pressures was statistically greater with the CCDA than with the Evans. The average increase in pressure under the fifth metatarsal head in the foot-flat phase was 46% +/- 42% (range-4% to 141%) with the Evans and 104% +/- 58% (range 9% to 216%) with the CCDA (p = 0.003). In the early heel-rise phase, the increase in pressure was 50% +/- 43% (range 2% to 108%) and 96% +/- 65% (range 12% to 263%), respectively (p = 0.02). CONCLUSION: The experimental data suggest that lateral column overload may be more likely with the CCDA than with the Evans. Physicians should be aware of the likelihood of increasing lateral column loads with both the CCDA and the Evans procedure. It may be possible to avoid this problem by using less lateral column lengthening than the 1 cm used in this study or by considering a medial column arthrodesis or plantarflexion osteotomy to balance forefoot loading.     

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.     

第1跖跗关节骨折脱位不同内固定方式对前足足底压力变化的影响

目的 :测量第1跖跗关节骨折脱位3种内固定对前足足底压力的变化,为选择内固定提供实验参考。方法:取8具新鲜足标本,制成第1跖跗关节骨折脱位模型,依次进行3.5 mm全螺纹皮质骨螺钉,1/4管形钢板及加压骑缝钉固定。经加载600 N后,通过F-scan足底压力分析系统,测量前足足底压力的变化。结果:第1跖跗关节骨折脱位后,第1跖骨头下的峰值压力将减小,而第2跖骨头下的峰值压力将增大,差异具有统计学意义(P<0.05)。对第1跖跗关节分别采用螺钉、钢板进行固定后,第1、2跖骨头下的峰值压力都将趋于正常状态,而进行骑缝钉固定后,虽然第1、2跖骨头下的峰值压力都有所恢复,但仍与正常状态比较,差异有统计学意义(P<0.05)。结论 :当第1跖跗关节骨折脱位后,邻近跖骨头可能存在着"负荷转移"的调节机制以代偿部分足底压力;当第1跖跗关节骨折脱位采用螺钉和钢板内固定治疗后,前足足底压力都可恢复至正常状态,而若采用骑缝钉固定,则前足足底压力仍难以恢复至正常状态。     

Geometric analysis of the Weil osteotomy

BACKGROUND: The Weil osteotomy has been reported to be a clinically effective treatment of metatarsalgia and intractable plantar keratosis. The plantar inclination of the metatarsal influences the effect of the osteotomy but has never been studied in detail. METHODS: This study examined five fresh or fresh-frozen cadaver specimens. The data obtained from the specimens was used to model the geometry of the Weil osteotomy. The effect of thick saw blades on the Weil osteotomy was determined. RESULTS: The inclination of the second metatarsal averaged 24.6 (range 19 to 31) degrees. The displacement of the capital fragment in the plantar direction was dependent on the angle of the osteotomy and the inclination of the metatarsal. A 5-mm proximal displacement along a 25-degree osteotomy displaced the capital fragment in a plantar direction if the inclination of the metatarsal was 19 degrees and displaced it dorsally if the inclination was 25 degrees or more. CONCLUSIONS: The results of this study showed that a thick saw blade could offset a portion of the plantar displacement of the capital segment that can occur with the Weil osteotomy. A 1-mm thick saw blade is recommended for most osteotomies, and a 2-mm thick saw blade is recommended for shortening of more than 5 mm or with plantar inclination of the lesser metatarsal of less than 19 degrees. A thicker saw blade should be considered for the treatment of plantar keratosis.     

Plantar pressure distribution and pain after distal osteotomy for hallux valgus: A prospective study of 22 patients with 12-month follow-up

BackgroundElevated pressure under the central forefoot region is common in hallux valgus and this is often associated with metatarsalgia.ObjectiveTo ascertain whether there was a difference in pain and plantar pressure distribution parameters after correction of the deformity by two distal metatarsal osteotomy techniques.MethodsTwenty-two patients randomly assigned to distal chevron or Lindgren first metatarsal osteotomy were evaluated prospectively with dynamic plantar pressure measurement, quality of life scores and clinical and radiographic measurements. Data were collected pre-operatively, at 6 and 12 months after surgery. Results of the combined operated group were compared with an age-matched control group.ResultsThere were no significant differences in plantar pressure distribution parameters between the two operated groups at any occasion. At 6 months peak pressure was significantly less under the lateral forefoot in the operated feet compared with the non-operated feet and significantly greater under the central forefoot than in the control group and the medial forefoot than under the non-operated feet, although the operated group had normalised after 12 months. The visual analogue scale (VAS) showed significant improvements after both surgical techniques.ConclusionBoth surgical techniques resulted in significant clinical and radiographic improvements and reduced the level of pain, although the foot pressure recordings demonstrated no biomechanical effect.     

Calcaneocuboid distraction arthrodesis and first metatarsocuneiform arthrodesis for correction of acquired flatfoot deformity in a cadaver model

BACKGROUND: Lateral column lengthening has been associated with residual forefoot supination and symptomatic lateral overload in treatment of acquired flatfoot. A medial column procedure may be useful to redistribute load to the medial column. We evaluated radiographic and pressure changes in a severe flatfoot model with lateral column lengthening and investigated the effect of an added first metatarsocuneiform arthrodesis. METHODS: Ten cadaver specimens were loaded in simulated double-legged stance, and radiographic and pressure data were collected for all tested states. Calcaneocuboid arthrodesis was done with a 10-mm foam wedge. Residual forefoot varus was corrected through the first metatarsocuneiform joint. RESULTS: Differences in the mean lateral talar-first metatarsal angle, talonavicular angle, talocalcaneal angle, and calcaneal pitch were significant between the intact foot and the flatfoot. After calcaneocuboid distraction arthrodesis and tendon transfer, the lateral talar-first metatarsal angle, talonavicular angle, and calcaneal pitch were significantly different from the flatfoot. After added first metatarsocuneiform arthrodesis, the talonavicular angle was not significantly different from the intact foot. Lateral forefoot pressure increased in the flatfoot after lateral column lengthening but was not significantly different from the intact foot after first metarsocuneiform arthrodesis was added. CONCLUSIONS: Adding first metatarsocuneiform arthrodesis to calcaneocuboid distraction arthrodesis for treatment of flatfoot deformity provided improvement in radiographic and pedobarographic parameters of a severe model of stage II posterior tibial tendon dysfunction.     

Second metatarsal osteotomies for metatarsalgia: A robotic cadaveric study of the effect of osteotomy plane and metatarsal shortening on plantar pressure

Symptom relief of recalcitrant metatarsalgia can be achieved through surgical shortening of the affected metatarsal, thus decreasing plantar pressure. Theoretically an oblique metatarsal osteotomy can be oriented distal to proximal (DP) or proximal to distal (PD). We characterized the relationship between the amount of second metatarsal shortening, osteotomy plane, and plantar pressure. We hypothesized that the PD osteotomy is more effective in reducing metatarsal peak pressure and pressure time integral. We performed eight DP and eight PD second metatarsal osteotomies on eight pairs of cadaveric feet. A custom designed robotic gait simulator (RGS) generated dynamic in vitro simulations of gait. Second metatarsals were incrementally shortened, with three trials for each length. We calculated regression lines for peak pressure and pressure time integral vs. metatarsal shortening. Shortening the second metatarsal using either osteotomy significantly affected the metatarsal peak pressure and pressure time integral (first and third metatarsal increased, p < 0.01 and <0.05; second metatarsal decreased, p < 0.01). Changes in peak pressure (p = 0.0019) and pressure time integral (p = 0.0046) were more sensitive to second metatarsal shortening with the PD osteotomy than the DP osteotomy. The PD osteotomy plane reduces plantar pressure more effectively than the DP osteotomy plane. Published 2013 by Wiley Periodicals, Inc. on behalf of the Orthopaedic Research Society. J Orthop Res 32:385–393, 2014.     

Pull-out technique for plantar plate repair of the metatarsophalangeal joint

Plantar plate rupture is a common cause of forefoot pain, multiplanar malalignment, subluxation, or dislocation of the metatarsophalangeal joint (MTPJ). The treatments that have been described for MTPJ instability of lesser toes include amputation, lengthening and/or tendon transfer, periarticular soft-tissue release (capsule, collateral ligaments, and plantar plate), colateral ligament reconstruction, metatarsal shortening osteotomy, and suture of plantar plate lesion. This article outlines the anatomy, pathogenesis, and diagnosis of plantar plate rupture, and describes a new technique that combines joint decompression by Weil osteotomy with?a plantar plate repair using a pull-out technique.