Metatarsal bars more effective than metatarsal pads in reducing impulse on the second metatarsal head

Background

The second metatarsal head is commonly involved in cases of metatarsalgia. As part of the conservative treatment, metatarsal bars and metatarsal pads are often prescribed.

Objective

To compare the effectiveness of metatarsal bars and metatarsal pads in reducing impulse on the second metatarsal head.

Method

Thirty-five healthy subjects were monitored with an insole scanning system during walking in four different conditions: (a) wearing shoes only, (b) shoes plus metatarsal pads and shoes plus metatarsal bars, placed either (c) perpendicular to the foot axis or (d) oblique to the foot axis. The impulse under the second metatarsal head was measured using the first condition as a control. Both feet were examined in each subject resulting in a total of 840 measurements.

Results

Both metatarsal bars and metatarsal pads were effective in reducing impulse when compared with the control (P < 0.01). Metatarsal bars were found to be more effective in reducing impulse as compared to the metatarsal pads (P < 0.01), and the oblique position of the bars was more effective than the perpendicular one (P < 0.01).

Conclusions

The greatest reduction of impulse on the second metatarsal head in healthy subjects is achieved with the use of metatarsal bars in an oblique position.     

Degenerative osteoarthritis of the second metatarsophalangeal joint: second toe rigidus

Purpose

The purpose of this study was to evaluate the radiographic characteristics and structural configurations of a series of patients with a primary degenerative arthritis of the second metatarsophalangeal joint.

Methods

We studied 37 feet that had undergone surgical treatment for primary degenerative arthritis of the second metatarsophalangeal joint. The patients were compared with a randomly selected control group, without arthritis of the second metatarsophalangeal joint. The first, second, and fourth metatarsal lengths, and the size of the second metatarsal head were measured on weight-bearing anteroposterior radiographs. The patients were classified on the basis of joint-space narrowing, subchondral sclerosis, osteophyte formation, and subchondral cystic change.

Results

The average second metatarsal length was significantly longer in the study group (P = 0.01). The average length of the first metatarsal relative to the fourth metatarsal was significantly shorter (P = 0.02) in the study group, while the average length of the second metatarsal relative to the fourth metatarsal was significantly longer (P = 0.01) in the study group. The average diameter of the second metatarsal head was significantly larger in the study group (P = 0.00), and the average ratio of this diameter relative to the length of the fourth metatarsal was significantly higher in the study group (P = 0.00). A total of four feet were classified as grade 0, nine as grade 1, 17 as grade 2, and seven as grade 3.

Conclusions

Second toe rigidus should be considered as a diagnosis in patients with painful limited dorsiflexion of the second metatarsophalangeal joint without evidence of Freiberg’s infraction or trauma.     

BioFoot in-shoe system: Normal values and assessment of the reliability and repeatability

BackgroundBioFoot^® is an in-shoe system to measure plantar pressures at the interface between the shoe and the sole of the foot. Since reliability and good repeatability are necessary to ensure the consistency of measurements on which clinical judgements are based, the aim of the study was to assess the reliability and repeatability of the BioFoot^® system and identify normal values for healthy subjects.Materials and methodsThirty subjects, 18 women and 12 men, were measured twice, with a 7–10 day interval between the sessions, wearing the same kind of shoes. In each session, three trials were recorded. The foot was divided into ten areas: heel, midfoot, whole forefoot, 1st–5th metatarsal heads, hallux, and lesser toes.ResultsThe intra-class correlation coefficients were between 0.76 and 0.96 for all four variables evaluated. The coefficient of variation between two sessions was around 7% (range: 4.6–9%). The mean contact time was 0.81 s, and walking cadence was 101.5 steps per minute. The pressure measurements showed the greatest peak and mean pressures under the second metatarsal head, and the second peak and mean pressures under the third metatarsal head.ConclusionThe plantar pressure measurements showed good to excellent consistency, and it was concluded that the BioFoot^® in-shoe system has good reliability and is repeatable. The highest values were found beneath the forefoot, which is consistent with the literature.     

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.     

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。     

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.     

Influence of the Length Ratio Between Second and Third Metatarsals After Modified Weil Osteotomy on Clinical Outcomes

Metatarsalgia is a frequent foot disorder. The objective was to evaluate whether the length ratio between the second and the third metatarsals after Weil osteotomy influences clinical outcomes. This retrospective study included 37 patients (53 feet). Preoperative planning consisted of keeping the second metatarsal greater than or equal to the third metatarsal after Weil osteotomy of the second metatarsal or the second and third metatarsals. Based on postoperative weightbearing and digital AP radiographs after Weil osteotomy, we divided the patients into 2 groups: group 1, the second metatarsal was longer than or equal to the third metatarsal; and group 2, the second metatarsal was shorter than the third metatarsal. We investigated whether there were differences between the groups. In 35 (66%) feet, the second metatarsal was longer than or equal to the third metatarsal (group 1), and in 18 (34%) feet, the second metatarsal was shorter than the third metatarsal (group 2). Postoperative American Orthopaedic Foot and Ankle Society scores were 86.2 and 82.7, respectively (p = .32). Postoperative Visual Analog Scale scores were 1.26 and 1.67, respectively (p = .39). The sample showed 11.3% of transfer metatarsalgia to the third metatarsal. Group 1 had 9% of transfer metatarsalgia, whereas group 2 had 17% of transfer metatarsalgia (p = .40). The presence of a second metatarsal shorter than the third metatarsal, after Weil osteotomy of the second metatarsal or the second and third metatarsals, does not influence outcomes or incidence of transfer metatarsalgia to the third metatarsal.     

The Effect of Landing Surface on the Plantar Kinetics of Chinese Paratroopers Using Half-Squat Landing

The objective of the study was to determine the effect of landing surface on plantar kinetics during a half-squat landing. Twenty male elite paratroopers with formal parachute landing training and over 2 years of parachute jumping experience were recruited. The subjects wore parachuting boots in which pressure sensing insoles were placed. Each subject was instructed to jump off a platform with a height of 60 cm, and land on either a hard or soft surface in a half-squat posture. Outcome measures were maximal plantar pressure, time to maximal plantar pressure (T-MPP), and pressure-time integral (PTI) upon landing on 10 plantar regions. Compared to a soft surface, hard surface produced higher maximal plantar pressure in the 1^st to 4^th metatarsal and mid-foot regions, but lower maximal plantar pressure in the 5^th metatarsal region. Shorter T- MPP was found during hard surface landing in the 1^st and 2^nd metatarsal and medial rear foot. Landing on a hard surface landing resulted in a lower PTI than a soft surface in the 1^stphalangeal region. For Chinese paratroopers, specific foot prosthesis should be designed to protect the1^st to 4^thmetatarsal region for hard surface landing, and the 1^stphalangeal and 5^thmetatarsal region for soft surface landing.

Key Points

• Understanding plantar kinetics during the half-squat landing used by Chinese paratroopers can assist in the design of protective footwear.
• Compared to landing on a soft surface, a hard surface produced higher maximal plantar pressure in the 1^st to 4^th metatarsal and mid-foot regions, but lower maximal plantar pressure in the 5^th metatarsal region.
• A shorter time to maximal plantar pressure was found during a hard surface landing in the 1^st and 2^nd metatarsals and medial rear foot.
• Landing on a hard surface resulted in a lower pressure-time integral than landing on a soft surface in the 1^st phalangeal region.
• For Chinese paratroopers, specific foot prosthesis should be designed to protect the 1^st to 4^th metatarsal region for a hard surface landing, and the 1^st phalangeal and 5^th metatarsal region for a soft surface landing.

Key words: Half-squat landing, plantar kinetics, plantar pressure, surface reaction force, pressure time integral     

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.

     

Synostosis between first and second metatarsal joint following Mitchell’s osteotomy

Background  Complications in the form of avascular necrosis, non-union, malunion have been reported following Mitchell’s osteotomy but no report of synostosis between first and second metatarsal have been reported. A case of cross union between first and second metatarsal following Mitchell’s osteotomy for hallux valgus in a 57-year-old lady is presented. This patient had Mitchell’s osteotomy on both her feet 7 years back. She presented with tingling in her toes and swelling in first web space. X-ray of the left foot showed bony bridge between distal third of first and second metatarsal. Conclusion  Cross union between the first and second metatarsal is rare to follow first metatarsal osteotomy. This can be symptomatic, the procedure described can cure the problem, and the condition needs to be prevented to avoid aggressive soft tissue damage and haematoma by rough handling of osteotomy displacement and not by using dorsolateral approach for hallux valgus surgery.     

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.     

Does it matter how we measure metatarsal length?

Introduction

Variations in the relative lengths of the metatarsal bones have been implicated as a cause of forefoot pain. Osteotomies to balance the metatarsal lengths have been described as therapy. Although measurement of metatarsal length is required for these osteotomies, there is no gold standard method to measure it radiologically. We compared the three main radiological methods to measure the second metatarsal length described in the literature.

Materials and Methods

Standing dorsoplantar radiographs of 81 feet were measured using the methods described by Coughlin, Maestro and Hardy and Clapham. Bland and Altman's method was used to compare the above techniques for reproducibility and agreement between each method.

Results

The three methods produced markedly different results. Coughlin's and Maestro's methods showed a relative protrusion of the second metatarsal—relatively longer than the first metatarsal by an average of 4 & 3 mm respectively. Hardy and Clapham's method, however, showed a relative retraction of second metatarsal by an average of 1 mm. Both intra-observer and inter-observer errors were smallest for the Coughlin method (the most reproducible) and largest for the Hardy/Clapham method. Significant lack of agreement was found when we compared the 3 techniques with bias for measuring the mean between methods ranging from 1 mm to 5.5 mm.

Conclusions

Metatarsal lengths as measured by these three methods can be very variable. Thus their role in planning metatarsal osteotomies and establishing relationship of metatarsal protrusion with metatarsophalangeal joint instability and other similar conditions is questionable and require further studies.     

Distal metatarsal coalition: A rare case report

IntroductionMetatarsal coalition is an extremely rare condition. We report the second documented case of 4th and 5th distal metatarsal coalition in the literature.Presentation of caseAn eight-year-old girl was referred to an orthopaedic clinic with a four-month history of forefoot pain and swelling on the plantar aspect of the right little toe. Radiograph and clinical examination confirmed distal metatarsal coalition between the 4th and 5th metatarsals. Following a period of conservative treatment, excision was eventually performed due to worsening symptoms. Patient re-attended two years later with a recurrence of the coalition confirmed by computed tomography (CT) scan. The case was discussed at a tertiary paediatric orthopaedic insititution. Decision was made to manage patient conservatively with insole and physiotherapy until skeletal maturity. A year later, patient’s symptoms did not worsen, and her foot displayed no evidence of change in the arch and shape.DiscussionThe timing of ossification of coalition varies from one anatomical site to another. Surgery when performed before ossification is complete runs the risk of recurrence.ConclusionOur case report illustrates the importance of restoring normal weight bearing dynamics and pain relief when managing metatarsal coalition, or synostosis in skeletally immature patients. We recommend persevering with conservative treatment, with operative treatment reserved only as a later option, and ideally, until skeletal maturity is achieved.     

The Effect of Hallux Valgus Surgery on the Transverse Plane Hallux Proximal Phalanx Position

The objective of this investigation was to evaluate the apparent movement of the hallux proximal phalanx in the transverse plane relative to the second metatarsal following hallux valgus surgery. Pre- and postoperative radiographs of a consecutive series of 45 feet undergoing hallux valgus surgery were analyzed. Significant improvements were observed in the first intermetatarsal angle (12.4 vs 7.5 degrees; p < .001), hallux valgus angle (24.3 vs 13.4 degrees; p < .001), tibial sesamoid position (4.6 vs 2.7; p < .001), and second metatarsal-hallux proximal phalanx angle (80.1 vs 84.6 degrees; p < .001). No difference was observed in the distance between the second metatarsal bisection and the medial aspect of the tibial sesamoid (31.7 vs 31.5 mm; p = .756) nor between the second metatarsal bisection and medial aspect of the hallux proximal phalanx base (34.6 vs 34.2 mm; p = .592). Significant differences were observed between the second metatarsal bisection and the central aspect of hallux proximal phalanx base (26.5 vs 23.9 mm; p < .001) and between the second metatarsal bisection and the lateral aspect of the hallux proximal phalanx base (19.3 vs 15.4 mm; p < .001). A statistically significant difference was observed in the change of distance between the second metatarsal bisection and the medial, central, and lateral aspects of the hallux proximal phalanx base (-0.4 vs -2.6 vs -3.9 mm; p = .002). These results indicate that the hallux proximal phalanx does not translocate in the transverse plane following hallux valgus surgery, but instead pivots about the medial aspect of the joint.     

The effect of pre-fabricated insole on plantar pressure distribution in patients with rheumatoid arthritis

BackgroundFoot deformities result in pain and changes in plantar pressure distribution in rheumatoid arthritis (RA) patients. Medical insoles are commonly prescribed for declining pain and modifying foot pressure distribution in these patients. The purpose of this study was to evaluate the effect of a pre-fabricated insole with metatarsal pad and medial longitudinal arch support on plantar pressure distribution in rheumatoid arthritis patients.MethodsFifteen females with RA participated in this study. All patients received a pair of pre-fabricated insoles that were individually modified using metatarsal pads and medial longitudinal arch supports. Mean peak pressure (kPa), maximum force (N), and contact area (cm²) were calculated for the heel, midfoot, metatarsophalangeal joint, and toe regions using the Pedar-X system immediately and after a month follow-up.FindingsIn the heel and metatarsophalangeal joint regions, maximum pressure and force showed a significant reduction in the follow-up assessment (p < 0.05). The comparison showed a significant increase in maximum pressure and force in the midfoot when participants walked with insole compared to without insole condition (p < 0.001).InterpretationUsing a pre-fabricated insole with an individually modified metatarsal pad and medial longitudinal arch support could alter rheumatoid arthritis patients’ plantar pressures after one month of follow-up. This type of insole is simple and inexpensive and showed a significant effect on decreasing pressures under the metatarsal heads.     

Iatrogenic second transfer metatarsalgia and the first metatarsal shortening and elevation after Scarf osteotomy

BackgroundTransfer metatarsalgia is a potential complication of hallux valgus surgery. This study aimed to investigate the shortened first metatarsal length and elevation and to compare groups with and without second transfer metatarsalgia after Scarf osteotomy.MethodsThe first metatarsal length of 123 feet was measured via the Maestro’s method using the metatarsal axial length and the relative second metatarsal protrusion to the first metatarsal. Metatarsal elevation was measured using the first metatarsal angle.ResultsSecond transfer metatarsalgia occurred after Scarf osteotomy in 11 (8.9%) feet. When baseline characteristics were considered in propensity score matching, the 11 feet were compared with the 33 feet in the control group. The group with transfer metatarsalgia showed a more shortened first metatarsal axial length (?4.1 ± 1.8 mm vs. ?2.5 ± 2.2 mm, p = 0.032), a significantly longer relative second metatarsal protrusion (+5.8 ± 2.6 mm vs. +1.2 ± 2.6 mm, p < 0.001), and a significantly lower first metatarsal angle (18.1 ± 4.3° vs. 21.5 ± 4.0°, p = 0.012) than the control group postoperatively.ConclusionsTo avoid iatrogenic transfer metatarsalgia, first metatarsal length shortening should be minimized to at least less than 4.0 mm. Furthermore, the metatarsal parabola should be retained.     

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.     

足底压力测试系统在第1跖楔关节融合术后的疗效评价

目的 :探讨足底压力测试系统对第1跖楔关节融合术后疗效的分析评价。方法:2013年6月至2014年1月,采用第1跖楔关节融合术治疗16例(20足)拇外翻伴第1序列不稳定患者,均为女性;年龄42~52岁,平均(46.5±2.9)岁;病程3~5年,平均2.5年。另选取20名健康女性为正常对照组,只选取单侧1足,共20足,年龄41~55岁,平均(46.8±4.5)岁。手术前后采用AOFAS评分系统对患足的功能。采用Foot Scan足底压力测试系统,记录并比较手术前后患足及正常对照组足第1~5跖骨头下的动态峰值压力、压强及冲量指标。结果:所有患者获得随访,时间24~30个月,平均27.4个月。术后患足拇外翻畸形得到纠正,第2跖骨头下痛性胼胝体消失。术前患足AOFAS评分(45.55±12.28)与术后(85.45±6.76)比较差异有统计学意义(P0.05);患足第1跖骨头下峰值压力、压强术前较正常组减少,差异有统计学意义(P0.05);患足第2骨头下峰值压力、压强及冲量术前较正常对照组增加,差异有统计学意义(P0.05);患足第1跖骨头下峰值压力、压强术后较术前增加,差异有统计学意义(P0.05),但与正常对照组比较差异无统计学意义(P0.05);患足术后第2跖骨头下3项指标较术前明显减少,差异有统计学意义(P0.05),与正常对照组比较差异无统计学意义(P0.05);手术前后第4、5跖骨头与正常组比较无统计学意义(P0.05)。结论:第1序列不稳定患足第1、2跖骨头下的压力与正常足有明显区别,行第1跖楔关节融合术可恢复第1、2跖骨头下正常的足底压力,而通过足底压力分析可进一步评价手术疗效。     

Peroneus brevis tendon in proximal 5th metatarsal fractures: Anatomical considerations for safe hook plate placement

IntroductionThe peroneus brevis tendon (PBT) inserts into the proximal aspect of the 5th metatarsal. Metatarsal bone fractures are encountered to be the most common fractures in the foot with predominantly fractures at the base of the fifth metatarsal bone. Mechanism of injury and treatment of the proximal 5th metatarsal fractures vary due to the complex anatomy and diverse biomechanical properties. The purpose of this study was to analyze the footprint of the PBT with regards to the proximal 5th metatarsal fractures and to define a “safe zone” for hook plate placement.Materials and methodsForty-one (41) fixed human lower leg specimens were dissected to expose the PBT insertion. The following footprint characteristics were evaluated: area of insertion (AOI) (mm²), length (mm), width (mm), shape and insertional variations. The position of the main PBT footprint was localized according to the Lawrence and Botte classification for the proximal 5th metatarsal fractures (Zone I–III). A “safe zone” was defined for the fracture-specific hook plate placement.ResultsIn 25 (61%) feet the PBT footprint was situated in Zone I and in 16 feet (39%) in Zone I&II. The mean AOI, length and width measured 54.5 mm² (SD 16.5), 16.0 mm (SD 5.1) and 4.7 mm (SD 1.4), respectively. Analysis of the footprint shapes revealed four different shape types: kidney (29.3%), diamond (22.0%), crescent (31.7%) and oval (17.0%). A “safe zone” for hook plate placement without or minimal interference of the PBT at its insertion could be defined at the lateral aspect of the 5th metatarsal.ConclusionThe majority of the PBT footprints were found in Zone I. Hook plate placement demonstrated to be safe when placed strictly laterally at the proximal aspect of the 5th metatarsal. Precise knowledge of the peroneus brevis anatomy may help to better understand the biomechanical aspects of the proximal 5th metatarsal fractures.     

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.