Restoration and Preservation of First Metatarsal Length Using the Distraction Scarf Osteotomy

The authors reviewed the records of 8 patients who underwent a distraction scarf osteotomy of the first metatarsal, and report the radiographic outcomes achieved with this procedure. The osteotomy was used to reestablish or maintain the length of the first metatarsal, without the use of a structural bone graft. The osteotomy was used as part of a revisional procedure for a failed bunionectomy in 4 patients. In the remaining patients, the procedure was used to preserve the length of the first metatarsal in conjunction with a Lapidus arthrodesis. The first and second metatarsals were measured radiographically, and the length of the first metatarsal was expressed as a percentage of the length of the second metatarsal. The average proportional increase in first metatarsal length obtained in the patients undergoing correction of the shortened first metatarsal was 7.08%, and the difference between the pre- and postoperative length of the first metatarsal was statistically significant (P = .0013) in these patients. Relative shortening of the first metatarsal was avoided in those patients undergoing distraction scarf osteotomy in conjunction with Lapidus arthrodesis. ACFAS Level of Clinical Evidence: 4.     

An association between functional second metatarsal length and midfoot arthrosis

BACKGROUND: Primary tarsometatarsal arthrosis is relatively uncommon. The etiology of osteoarthritis in the foot is poorly understood, and it is possible that mechanical or anatomic factors play a role. METHODS: We compared the relative length of the metatarsals in patients with idiopathic arthrosis of the midfoot with that in a group of controls without arthrosis. We analyzed the radiographs of all patients who had had an arthrodesis of the first, second, and third tarsometatarsal joints to treat arthrosis during a three-year period at a tertiary teaching hospital. We excluded patients with a history of inflammatory arthritis, trauma, or Charcot arthropathy. Nine patients (fifteen feet), seven women and two men with an average age of 64.2 years, met the inclusion criteria. We compared them with a control group consisting of the uninjured feet of patients with an acute traumatic injury to the hindfoot and the feet of volunteers with no foot problems. We measured the first, second, and fourth metatarsal lengths and the intermetatarsal angles on weight-bearing anteroposterior radiographs. We also measured the length of the first metatarsal relative to the long axis of the second metatarsal to define the functional first metatarsal length. The ratios of metatarsal lengths and the ratios of functional lengths were used for analysis to minimize differences in foot size and differences caused by radiographic magnification. Statistical comparisons between groups were then carried out. RESULTS: In the study group, the length of the first metatarsal was, on the average, 77.0% of the length of the second metatarsal, whereas, in the control group, the first metatarsal length was an average of 82.0% of the second metatarsal length. The functional length of the second metatarsal was, on the average, 18.6% greater than that of the first metatarsal in the study group and only an average of 4.1% greater than that of the first metatarsal in the control group. Both differences were significant (p < 0.0004 and p < 0.0001, respectively). CONCLUSIONS: Patients with midfoot arthrosis had a different ratio of the first to the second metatarsal length than did a similarly aged cohort without midfoot arthrosis. The patients had a relatively short first metatarsal or a relatively long second metatarsal, or both. Midfoot arthrosis may have a mechanical etiology. Recognition of risk factors is the first step in developing prevention strategies.     

The epidemiology of metatarsal fractures

BACKGROUND: Metatarsal fractures are common injuries; however little has been written regarding their epidemiology in an adult population. METHODS: All patients with metatarsal fractures during a 1-year time period were included in the study. Demographic information, grade, and mechanism of injury, associated injuries, and fracture location and type were recorded. RESULTS: Three hundred and fifty-five patients with 411 metatarsal fractures were identified. The average age of the patients was 42 years. There was a higher proportion of women in the higher age groups, and the most common fracture was that of the fifth metatarsal. Multiple metatarsal fractures occurred in contiguous metatarsals, and 63% of third metatarsal fractures were associated with a fracture of either the second or fourth metatarsal. CONCLUSION: Knowledge of the epidemiology and injury patterns of metatarsal fractures can aid in the accurate identification and subsequent treatment of fractures of the metatarsals.     

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.     

Proximal fourth metatarsal injuries in athletes: similarity to proximal fifth metatarsal injury

Proximal fourth metatarsal injuries are rarely reported. We present five case histories in which athletic patients sustained injuries at the shaft-base junction of the fourth metatarsal. Similar to proximal fifth metatarsal injuries, adduction of the forefoot appears to be associated. Our patients returned to their activities in two to eight months. These patients injuries tended to take longer to heal than other lesser metatarsal fractures and stress fractures (which are typically more distal). Some patients were continually symptomatic, even after three months of rest and immobilization. This coincides with proximal fifth metatarsal injuries and stress fractures. For treatment of proximal fourth metatarsal injuries to be successful, ideal treatment appears to involve nonweightbearing below-knee cast/boot immobilization for three weeks. This is followed by an additional three or more weeks of weightbearing immobilization. Healing may still be prolonged.     

The zero-plus first metatarsal and its relationship to bunion deformity

The relationship between first metatarsal length and hallux valgus (HV) deformity was examined. Retrospectively, 210 randomly selected radiographic files were reviewed between 1988 and 1993. The morbid population consisted of 110 feet with HV deformities. The control population consisted of 100 healthy feet (no deformity). Seventy-seven percent of the patients with HV deformity had a first metatarsal length that was equal to or longer than the second metatarsal. This was defined as a zero-plus first metatarsal. Only 28% of the control population had this same proportion in length. Thus, prevalence of zero-plus first metatarsal was significantly associated with HV formation (χ²₁ = 51.15, P < .001). The mean first metatarsal protrusion distance was significantly higher in the bunion population (+1.58 mm) than in the control patients (−2.05 mm) (P < .001). The distribution of head shape differed significantly between the patients with HV and control patients; patients with HV had predominantly round heads (91%) and the control patients had predominantly square and square with a ridge heads (80%) (χ²₂ = 107.7, P < .001). All zero-plus first metatarsals in the HV population had a round first metatarsal head. Only 7.1% of the control patients had a round head with a zero-plus metatarsal. There was a positive relationship between the protrusion distance of the first metatarsal and the severity of the intermetatarsal angle, particularly in those patients with intermetatarsal angles ranging from 13° to 20° (P < .01). It was concluded that a zero-plus first metatarsal is a significant etiologic factor in the development of bunion deformity and should be part of the preoperative evaluation.     

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.     

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.     

Great toe-to-hand transfer: role of the preoperative lateral arteriogram of foot

This report correlates the results of the lateral angiogram of the foot with the operative dissection and eventual outcome in 29 patients in whom a great toe-to-hand transfer was performed to treat a traumatic loss of the thumb. Our angiographic findings were confirmed by surgical exploration and indicated that (1) in 20 (70%) of 29 patients the first dorsal metatarsal artery (FDMA) originated from the dorsalis pedis artery, dorsal to the midlongitudinal axis of the first metatarsal bone; (2) in 6 (20%) of 29 patients the FDMA originated from the dorsalis pedis artery, plantar to the midlongitudinal axis of the first metatarsal bone; (3) in the remaining 3 (10%) of 29 patients the arteriogram of the lateral foot indicated that the plantar metatarsal artery supplied the great toe in a dominant pattern, necessitating its use as the donor vessel; and (4) the measured lumenal diameters of the dorsal and plantar metatarsal arteries (mean diameter = 1.30 mm and 1.27 mm, respectively) did not significantly differ. The lateral views of the foot were helpful in permitting distinct identification of the location and size of the metatarsal arteries to the great toe.     

Brachymetatarsia of the first metatarsal treated by surgical lengthening.

The first metatarsal of six feet in four patients was surgically lengthened. Brachymetatarsia was caused by a congenital defect in two patients, nonunion after metatarsal osteotomy in one patient, and premature physeal closure associated with pin placement across the physis in one patient. In each patient, middiaphyseal osteotomy was performed, pins were placed into the proximal and distal metatarsal fragments, and an external distracting device was attached. After distraction, a fibular graft was inserted and the device was removed. The percentage of metatarsal length gained from the lengthening averaged 36% (range 12-68%). The fibular graft healed in the lengthened position in all patients.     

Surgery for symptomatic Freiberg's disease: extraarticular dorsal closing-wedge osteotomy in 13 patients followed for 2-4 years

From 1992 through 1995, we have treated 13 patients (10 men) with Freiberg's disease by debridement and dorsal closing-wedge osteotomy of the metatarsal neck. The lesion was located in the second metatarsal head in 10 patients and in the third metatarsal head in 3. After osteotomy, the lesion was away from the joint, so that the smooth and healthy articular cartilage of the metatarsal head faced the phalangeal cartilage. The average follow-up period was 40 (28-54) months. The subjective outcome was good or excellent in 11 patients, fair in 1, and poor in 1. We found MRI useful in determining the extent of the lesion when planning correction.     

Frontal Plane Rotation of the First Ray in Hallux Valgus using Standing Computerized Tomography (CT)

The purpose of the present study was to analyze the difference in frontal plane rotation of the entire first ray in patients with and without hallux valgus using standing weightbearing computed tomography (CT). Ten feet of 10 patients with hallux valgus and 36 feet of 36 patients without hallux valgus were examined. Standing weightbearing CT scans and radiographs were taken for all subjects. Frontal plane measurements of the sesamoid apparatus, first metatarsal head, first metatarsal base, and medial cuneiform were performed. Frontal plane rotation of the first tarsometatarsal joint and intrinsic first metatarsal torsion was calculated. An independent 2 sample t test was used to compare means of outcomes of interest across control and treatment groups. Statistical significance was set at an alpha level of 0.05. There was a significant increase in pronation of the sesamoid apparatus (23.49° vs 6.60°) and first metatarsal head (17.79° vs 9.81°) in patients with hallux valgus. There was a significant increase in first metatarsal torsion toward pronation in patients with hallux valgus (22.28° vs 13.52°). No significant difference was detected in the rotation at the first tarsometatarsal joint or the frontal plane orientations of the first metatarsal base and medial cuneiform. By examining the frontal plane position of the entire first ray during weightbearing using standing CT in patients with and without hallux valgus, we determined the level at which pronation originates to be within the first metatarsal bone rather than the first tarsometatarsal joint.     

Distraction osteogenesis for the shortened metatarsal after hallux valgus surgery

BACKGROUND: Shortening of the first metatarsal is known to occur during hallux valgus surgeries. If the shortened first ray disrupts the normal weight transfer, then transfer metatarsalgia may result. After failed conservative treatment, a common operative option is an osteotomy of the lesser metatarsals. However, osteotomies of normal metatarsals further alter the normal anatomy and can significantly shorten the forefoot. Restoration of first metatarsal length using distraction osteogenesis may more closely restore normal foot anatomy and biomechanics and subsequently treat transfer metatarsalgia. METHODS: Five patients had distraction osteogenesis for a shortened first metatarsal that resulted from a previous hallux valgus surgery. A four-pin single-plane external fixator was applied to the first metatarsal to lengthen the metatarsal under the principles of distraction osteogenesis. Lengthening was complete once the affected first metatarsal was equal to the length of the adjacent second metatarsal. RESULTS: The mean consolidation period was 15.8 weeks. Preoperative and postoperative length of the first metatarsal was expressed as a percentage of the length of the ipsilateral second metatarsal. The preoperative mean was 77.1% and the postoperative mean was 93.8%. All osteotomies went on to consolidation, and no grafting or secondary procedures were needed. There were no postoperative infections, malrotation, or malalignment. All patients reported reduction in their forefoot pain and returned to a nonantalgic, full weightbearing gait. CONCLUSIONS: This small series depicts the potential success of distraction osteogenesis for the iatrogenically shortened first metatarsal and associated transfer metatarsalgia.     

Chevron osteotomy in the treatment of hallux valgus

Fifty patients who underwent 80 chevron osteotomies for symptomatic hallux valgus were re-examined and assessed 4 years and 7 months (average) after surgery. Forty-five of the patients were satisfied with the result of their surgery, three patients suffered recurrence of their deformity and two had continuance of their symptomatology. The major complications noted were intraoperative intra-articular fracture of the metatarsal head in five feet, loss of initial repair in three feet, and tilt of the distal fragment (metatarsal head) in two feet. The Chevron osteotomy is a relatively simple procedure that corrects the varus deformity of the first metatarsal, realigns the valgus orientation of the metatarsal head, corrects the hallux valgus deformity, and improves symptomatology.     

Surgery for symptomatic Freiberg's disease: Extraarticular dorsal closing-wedge osteotomy in 13 patients followed for 2-4 years

From 1992 through 1995, we have treated 13 patients (10 men) with Freiberg's disease by debridement and dorsal closing-wedge osteotomy of the metatarsal neck. The lesion was located in the second metatarsal head in 10 patients and in the third metatarsal head in 3. After osteotomy, the lesion was away from the joint, so that the smooth and healthy articular cartilage of the metatarsal head faced the phalangeal cartilage.

The average follow-up period was 40 (28-54) months. The subjective outcome was good or excellent in 11 patients, fair in 1, and poor in 1. We found MRI useful in determining the extent of the lesion when planning correction.     

Amputation of the great toe. A clinical and biomechanical study

Clinical and biomechanical observations were made on otherwise normal feet in ten patients, who had had amputations for pollicization of the great toe. Measureable changes were demonstrated in the patients' gait pattern and in force plate data. The center of pressure was noted to shift from beneath the second metatarsal head on the normal side to beneath the third metatarsal head on the amputated side. The velocity of movement of the center of pressure slowed significantly in the metatarsal head region of the operated side, which secondarily resulted in an increased loading of the metatarsal region. The progression of the center of pressure was noted to be beneath the third metatarsal head region on the involved side, instead of progressing medially and distally toward the first web space. Clinically, the operated foot demonstrated slight thickening beneath the second and third metatarsal heads but no significant abnormal callus formation developed. The patients' shoes all showed increased lateral wear on the amputated side. From a functional standpoint, the patients had little or no disability from loss of the hallux.     

Stress fractures of the ankle and forefoot in patients with inflammatory arthritides

Twenty-four stress fractures occurring in the metatarsal bones and ankle region were examined in 17 patients with inflammatory arthritides. There were 16 metatarsal, four distal fibular, two distal tibial, and two calcaneus fractures. Radiographic analyses were performed to determine the presence of possible predisposing factors for stress fractures. Metatarsal and ankle region stress fractures were analyzed separately. Stress fractures occurred most frequently in the second and third metatarsals. In metatarsal fractures, there was a trend for varus alignment of the ankle to cause fractures of the lateral metatarsal bones and valgus alignment of the medial metatarsal bones. Valgus deformity of the ankle was present in patients with distal fibular fractures in the ankle region group. Calcaneus fractures showed neutral ankle alignment. Malalignment of the ankle and hindfoot is often present in distal tibial, fibular, and metatarsal stress fractures. Additionally, patients tend to have long disease histories with diverse medication, reconstructive surgery and osteoporosis. If such patients experience sudden pain, tenderness, or swelling in the ankle region, stress fractures should be suspected and necessary examinations performed.     

The Value of Radiographic Parameters in the Surgical Treatment of Hallux Rigidus

The purpose of this study was to determine if metatarsal protrusion or the length of the first and second rays were associated with the incidence of hallux rigidus. For this retrospective study, anteroposterior radiographs from 51 patients diagnosed with hallux rigidus and 51 patients without evidence of hallux rigidus were selected for review as a control group. Radiographs were randomly assigned to one of two raters who determined the metatarsal protrusion distance, first metatarsal length, second metatarsal length, length of the proximal phalanx of the hallux, length of the proximal phalanx of the second toe, and overall hallux length. A statistical comparison of these radiographic measurements showed only first metatarsal length to significantly differ (P = .05) between the two groups (65.4 +/- 5.3 mm and 67.7 +/- 5.9 mm for the hallux rigidus and control groups, respectively). The findings of this study suggest the need to revisit the role that metatarsal protrusion distance and first metatarsal length play in the etiology of hallux rigidus. In addition the need to surgically correct a long first metatarsal should be further evaluated.     

Treatment of brachymetatarsia by distraction osteogenesis

Metatarsal lengthening by distraction osteogenesis was performed on 17 brachymetatarsia patients with 39 metatarsal bones. To lengthen the first metatarsal in an attempt to prevent development of varus deformity of the hindfoot after lengthening, horizontal lengthening in the anterior direction was performed rather than lengthening through the anatomical axis. In addition, care was taken to ensure that the fourth metatarsal bone screw did not interpose with the fifth extensor tendon during the fourth metatarsal lengthening. Lengthening was successful except in 1 case with mean lengthening of 19.5 mm (48.8%) for the first metatarsal and 17.1 mm (36.2%) for the fourth metatarsal. Because of joint stiffness, plantar capsulotomy was performed on 7 cases, 6 of which had been previously operated on bilaterally. Varus deformity of the hindfoot after the first metatarsal lengthening and entrapment of the fifth extensor tendon after the fourth metatarsal lengthening was not detected in any case.     

跖底动脉皮瓣逆行转移修复趾皮肤缺损

目的探讨趾外伤或再造后皮肤缺损使用带蒂皮瓣修复的临床应用价值。方法 2003年9月～2009年9月用跖底动脉皮瓣逆行转移修复趾皮肤缺损21例。在足底设计以跖底动脉为蒂的跖底动脉皮支穿出点为中心的逆行皮瓣修复趾皮肤缺损,设计的跖底皮瓣宽度均小于3cm,供区可以直接缝合。再造时足部供区切取的面积较大,用跖底皮瓣修复趾骨外露创面,其余部分配合植皮。结果 21例跖底动脉皮瓣全部成活,8例外伤和4例Ⅰ度指尖缺损再造的趾供区直接用跖底皮瓣修复,9例拇甲瓣供区配合植皮。供区修复后外形良好,不需要二期整形。结论跖底动脉皮瓣逆行转移修复趾皮肤缺损,皮瓣薄、有神经支配、解剖位置恒定,是修复趾端小面积皮肤缺损的好方法。