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.     

The influence of the length of the first metatarsal on transfer metatarsalgia after Wu's osteotomy

BACKGROUND: The aim of this study was to evaluate how changes in the length of the first metatarsal, hallux valgus angle (HVA), intermetatarsal 1-2 angle (IMA), plantar angulation and sesamoid position influence the severity of the postoperative 2-5 metatarsalgia and to determine patient satisfaction with the cosmetic outcome after Wu's osteotomy. MATERIALS AND METHODS: A retrospective analysis of the clinical data and radiographs of 87 cases was performed at a mean followup time of 4.2 years after Wu's subcapital cross osteotomies. RESULTS: The mean HVA decreased from 42 to 13 degrees, the mean IMA 1-2 from 22 to 10 degrees. The mean first metatarsal lengthening was 0.3 mm. A negative correlation was found between lengthening of the first metatarsal and metatarsalgia at rays 2 and 3. No such pattern was found between the fourth and fifth metatarsal. No correlation was found between the 2-5 metatarsalgia and the decrease in either the HVA or the IMA 1-2. A positive correlation was detected between the HVA decrease and the patients' satisfaction with their postoperative foot alignment; there was no correlation between the perceived postoperative foot alignment and either the first metatarsal lengthening or the IMA 1-2 decrease. CONCLUSION: Preservation of the length of the first metatarsal during osteotomy seems to prevent the postoperative transfer metatarsalgia on the second and third rays; however, it has no major influence on the satisfaction of the patients with their foot alignment. A greater correction of the HVA angle resulted in a higher level of satisfaction with the foot cosmesis.     

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.     

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.     

Proximal crescentic metatarsal osteotomy: the effect of saw blade orientation on first ray elevation

BACKGROUND: Moderate and severe hallux valgus deformities generally require a proximal metatarsal osteotomy to correct a widened intermetatarsal angle. Although excellent results have been reported using the proximal crescentic osteotomy, concerns have been raised about the incidence of postoperative dorsal malunion, which may lead to transfer lesions. The objectives of this paper were to evaluate the influence of saw blade angulation on the final position of the first metatarsal and to test a new technique used to ensure proper orientation of the osteotomy. METHODS: For part I of the study, 26 Sawbones specimens with hallux valgus deformities were corrected using a proximal crescentic osteotomy with the saw blade position incrementally rotated in the coronal plane. The sagittal change in the final position of the metatarsal was quantified radiographically and correlated to the saw blade orientation. For part II of the study, a Kirschner wire was placed in a vertical position into the medial cuneiform to serve as a guide for the crescentic saw blade in 13 cadaver feet with hallux valgus. Metatarsus primus elevatus was measured after surgical correction. RESULTS: Part I of the study demonstrated a highly linear relationship (R2=0.95) between first metatarsal elevation and the orientation of the saw blade. Every 10-degree of saw blade angulation resulted in a 2-mm change in the sagittal position of the first metatarsal. In part II of the study, the average change in metatarsus primus elevation for the 13 specimens after surgical correction of the hallux valgus deformity was only 1.1 mm (range -3.9 to +4.9 mm). Eleven of the 13 specimens had less than 2.5 mm of elevatus. CONCLUSION: Dorsal malunion of the first metatarsal after proximal crescentic osteotomy is a recognized complication. The final position of the hallux metatarsal is influenced by the coronal plane orientation of the saw. A new technique is described to aid the surgeon in proper alignment of the saw and help prevent excessive first ray elevation.     

The metatarsal osteotomy: a 10-year follow-up on the second, third and fourth metatarsal osteotomies and a new approach to the fifth metatarsal osteotomy

The metatarsal osteotomy, a relatively simple procedure, provides a great amount of correction and relief with a limited amount of bone resection. Postoperative pain and edema are minimal, and disability and loss of time from employment are eliminated as patients are able to walk immediately in a surgical shoe. If biomechanical management is not adequate in relieving discomfort, then a 10-year study of more than 1000 cases indicates that the osteotomy is the procedure of choice.     

Distal osteotomy of the metatarsal bones in the treatment of metatarsalgia]

Authors review briefly the development of the principles of metatarsal osteotomies and the basic concepts that seem to be the most suitable in the choice of the type and execution of the operation. The effectiveness of the surgical treatment is stressed if the following viewpoints are considered: 1. Synchronous correction of the rays II, III, and IV. 2. Simultaneously achieved abbreviation and forming of the arch. 3. Instead of internal fixation transversal lifting bandage with early weight bearing. The finding, according which, beside the telescope osteotomy of Helal, Wolf's metatarsal osteotomy with axial deviation is also a valuable alternative, is supported by the follow-up of their own 2 years material.     

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.     

Measurement of the first/second intermetatarsal angle following proximal oblique metatarsal osteotomy

The radiographs of 21 consecutive patients who had undergone proximal oblique metatarsal osteotomy were reviewed. The first/second intermetatarsal and MP angles were measured before and after surgery using two different well-described methods. Values for each patient using the Hardy and Clapham and center-of-head methods were compared using a paired t-test. The degrees of angular correction obtained for the first/second intermetatarsal angle and MP joint were significantly different on the same foot as measured by the two different methods. Although we cannot choose between these two methods on the basis of this study, we hope to call attention to the discrepancy and urge readers to be cautious in comparing the results of studies until consensus may be reached regarding standard measurement of radiographic results.     

The assessment of adolescent hallux valgus before and after first metatarsal osteotomy

Summary A comprehensive method of evaluating the feet of patients with adolescent hallux valgus both before and after surgical correction is described. Serial clinical, photographic and radiological studies were made and a dynamic assessment of gait was carried out using a load-sensitive walkway. Observations were made on 36 feet in which hallux valgus was treated by a modification of the Wilson oblique metatarsal osteotomy, with removal of a wedge of bone and screw fixation. In the first six months after operation, there was a lateral shift of the weight-bearing pattern in the forefoot and less weight was taken on the toes, but there was a tendency to return to the pre-operative distribution of weight during the next four years. Persistence of the lateral shift of weight-bearing appeared to result from elevation of the first metatarsal head secondary to shortening of the first metatarsal during the osteotomy. This can be avoided by deliberate depression of the first metatarsal head at the time of operation and fixation of the fragments in the required position with a screw.

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Résumé Les auteurs décrivent une méthode d'évaluation globale du pied, tant avant qu'après correction chirurgicale, chez des adolescents porteurs d'hallux valgus. Elle nécessite une série d'études des caractéristiques cliniques, photographiques et radiologiques, ainsi qu'une évaluation dynamique de la marche à l'aide d'un plateau de force. Cette méthode a été utilisée pour estimer avec exactitude les modifications survenues sur 36 pieds après que l'hallux valgus ait été traité par une variante de l'ostéotomie oblique du premier métatarsien décrite par Wilson, qui consiste en une résection d'un coin osseux suivie de fixation par une vis. Durant les six premiers mois post-opératoires, on note un déplacement de l'appui de l'avant-pied vers le dehors et une diminution de la charge au niveau des orteils, mais il y a une tendance à revenir à la répartition pré-opératoire de l'appui au cours des quatre années suivantes. La persistance du déplacement externe de l'appui semble résulter de la surélevation de la tête du premier métatarsien, conséquence du raccourcissement de cet os créé par l'ostéotomie. Ceci peut être évité en abaissant délibérément la première tête métatarsienne lors de l'opération et en fixant les fragments par une vis dans la position désirée.

     

小切口第一跖骨远端截骨术矫正(足母)外翻畸形

目的:探讨小切口第一跖骨远端截骨术矫正蹄外翻畸形的疗效.方法:2003年以来采用小切口第一跖骨远端截骨术治疗(足母)外翻畸形300例共542只足,不做内固定.对所有患者采用美国骨科足踝外科学会(AOFAS)(足母)趾-跖趾-趾间评分标准进行临床评估,并结合影像学诊断综合评价手术疗效.结果:AOFAS总平均分为89.4±10.2分.影像学评估,术后(足母)外翻角(HVA)为12.8°±5.8°(4°～22°),较术前34.6°±9.6°(18°～68°)改善22°±8.4°;第一二跖骨间角(IMA)为7.6°±1.8(6°～11°),较术前14.3°±3.2°(11°～21°)改善6.7°±2.4°,P＜0.05表示有显著性差异.542只患足,498只对术后疗效满意,满意率91.5%.结论:小切口第一跖骨远端截骨术矫正(足母)外翻,临床效果可靠,不需内固定,手术切口美观,值得推广.     

Mobility changes of the first ray after hallux valgus surgery: clinical results after proximal metatarsal chevron osteotomy and distal soft tissue procedure

BACKGROUND: The purpose of this study was to evaluate the change of the first ray mobility after PMCO and DSTP in hallux valgus patients. MATERIALS AND METHODS: From May 2004 to December 2005, 82 PMCO with DSTP surgeries were performed for the management of hallux valgus deformity. The dorsiflexion mobility of the first ray of the foot was measured both preoperatively and 1 year after surgery using a modified Klaue device. The data were statistically analyzed with a paired t-test. An American Orthopedic Foot and Ankle Society (AOFAS) forefoot hallux score and patient satisfaction were also evaluated. RESULTS: Subjects consisted of 9 male and 73 female patients with an average age of 47.7 years (range, 19 to 74 years). The mean preoperative dorsiflexion mobility was 6.8 (range, 2.32 to 15.02) mm and the mean dorsiflexion mobility at one year after operation was 3.2 (range, from 1.7 to 5.4) mm. This decrease was statistically significant (p < 0.01). The mean preoperative AOFAS forefoot hallux score was 66.2 (range, 44 to 90) and improved to 89.1 (range, 72 to 100) by the 1-year followup (p < 0.01). CONCLUSION: Clinically, the dorsiflexion mobility of the first ray was significantly reduced after correction of hallux valgus with PMCO with DSTP. Because the stability of the first ray can be improved with PMCO with DSTP, the surgical indication for this procedure could include some patients showing hypermobility of the first ray.     

The Scarf first metatarsal osteotomy in the correction of hallux valgus deformity

The correction of hallux valgus has been dramatically improved by the scarf 1^st metatarsal osteotomy, which brings great versatility for covering all the indications. Its strong fixation allows an early functional recovery; the long-term follow-up confirms the reliability of this procedure, which can be combined with other osteotomies and soft tissue procedures. However, the surgeon has to determine pre and intraoperatively the correction that has to be applied; this technique is not difficult but has to be performed accurately. This is the interest of this article, which emphasizes the technical features that have to be applied.     

Chevron osteotomy of the first metatarsal for hallux valgus

A retrospective study of 50 chevron osteotomies evaluated subjective and objective functional and cosmetic results, which were in keeping with other reported studies--i.e. satisfactory subjective cosmesis in 98%; excellent or good pain relief in 84%; and satisfactory objective cosmesis in 84%. The correction of the 1st intermetatarsal angle averaged 3.3 degrees, and that of the metatarsophalangeal valgus averaged 15 degrees. Average active range of motion of the 1st metatarsophalangeal joint was 60 degrees. Complications were generally mild and asymptomatic, and were usually iatrogenic. The findings of this study, together with information gained from a concomitant stress analysis, led to recommendations regarding operative technique.     

第一跖列三平面截骨联合其余跖骨基底截骨治疗中重度跖内收型■外翻的早期疗效

目的探讨第1跖列三平面截骨联合其余跖骨基底截骨治疗中重度跖内收型[足母]外翻的早期疗效。方法2012年2月-2016年9月,收治10例(12足)中重度跖内收型[足母]外翻患者。男1例(2足),女9例(10足);年龄21~55岁,平均34.5岁。病程3~10年,平均5.8年。根据改良Sgarlato测量法对跖内收分度:中度4足、重度8足。术前美国矫形足踝协会(AOFAS)评分为(46.4±9.3)分;跖内收角(metatarsus adductus angle,MAA)为(25.41±3.66)°,[足母]外翻角(hallux valgus angle,HVA)为(41.42±9.67)°,第1-2跖骨间角(first-second intermetatarsal angle,1-2IMA)为(10.72±2.26)°。采用第1跖列三平面截骨联合其余跖骨基底截骨以及外侧软组织松解术治疗。结果术后切口均Ⅰ期愈合。患者均获随访,随访时间18~24个月,平均21.4个月。1例(1足)术后出现转移性跖痛,对症处理后症状消失。X线片复查示截骨部位均愈合,愈合时间为2.4~3.2个月,平均2.8个月。末次随访时,MAA为(8.42±0.71)°、HVA为(13.29±1.03)°、1-2IMA为(4.41±0.48)°,AOFAS评分为(89.8±5.9)分,均较术前明显改善(P<0.05)。结论第1跖列三平面截骨联合其余跖骨基底截骨治疗中重度跖内收型[足母]外翻,可获得较好早期疗效。     

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.     

Effect of minimally invasive distal first metatarsal osteotomy on blood flow of the metatarsal head

BackgroundDistal first metatarsal osteotomy is an option for operative treatment of mild to severe hallux valgus (HV) deformities. Minimally invasive distal linear metatarsal osteotomy (DLMO) provides good outcomes without avascular necrosis (AVN) of the metatarsal head. However, no reports have described the in vivo blood flow changes in the metatarsal head after osteotomy. This study was performed to evaluate the in vivo blood flow of the pre- and post-osteotomy metatarsal head in patients with HV using laser Doppler flowmetry and thus clarify the effect of minimally invasive distal first metatarsal osteotomy on the change in blood flow.MethodsFrom April 2015 to October 2016, DLMO was performed on 13 feet with HV in 10 patients (2 men, 8 women). Blood flow measurements of the pre- and post-osteotomy first metatarsal head in all feet were performed by laser Doppler flowmetry. AVN was evaluated using plain radiographs at the final postoperative follow-up.ResultsThe median pre- and post-osteotomy blood flow was 1.5 (0.97–1.95) and 1.46 (0.98–1.77) ml/min/100 g, respectively (median change in blood flow, 0.00; 95% CI, ?0.23–0.13; P = 0.72). The rate of change in the blood flow was 0.0% (95% CI, ?11.9%–8.7%; range, ?28.6%–64.7%), and only three patients (23.1%) showed a decrease of ≥10%. The median pre- and post-osteotomy systolic blood pressure was 90 (84.5–97) and 93 (84.5–95) mmHg, respectively (median change in blood pressure, 0.00; 95% CI, ?3.0–2.0; P = 0.82). The rate of change in the systolic blood pressure was 0.0% (95% CI, ?3.1%–2.2%; range, ?9.1%–24.0%). No radiographic evidence of AVN was present at the final follow-up.ConclusionsNo significant difference was found in the rate of change in blood flow pre- and post-osteotomy, suggesting that minimally invasive distal first metatarsal osteotomy does not influence blood flow of the metatarsal head.