Regional differences in the biological variability of plantar pressure as a basis for refining diagnostic gait analysis.

The variability of movement plays a crucial role in shaping individual's gait pattern and could, therefore, potentially serve diagnostic purposes. Nevertheless, existing concepts for the use of variability in diagnosing gait present a challenge due to the lack of adequate benchmarks and methods for comparison. We assessed the individuality of contribution of foot parts that directly mediate the transmission of forces between the foot and the ground in body weight shifting during walking based on 200 pedobarometric measurements corresponding to the analysed foot parts for each of 19 individuals in a homogeneous study group. Our results show a degree of individualisation of the contribution of particular foot parts in the weight-shift high enough to justify the need to consider it in the diagnostic analysis. Furthermore they reveal noticeable, functionally driven differences between plantar areas most apparent between the lowest individuality for the first foot ray and the highest for second one and metatarsus. The diagnostic reference standard in pedobarometry should describe the contribution in the shift of body weight during walking for each area of the foot separately and include information on the intra-individual variation and individualisation of descriptors of the contribution. Such a comprehensive standard has the potential to increase the diagnostic value of pedobarometry through enrichment of the assessment description.

Treatment of Freiberg's disease using a reverse pedicled metatarsal bone flap: Case report.

Despite no surgical procedures receiving unanimous support for treating Freiberg's disease, several surgical treatment options have been described. For the past few years, bone flaps have been shown in children to present promising regenerative properties. We report a novel technique using a reverse pedicled metatarsal bone flap from the first metatarsal to treat one case of Freiberg's disease in a 13-year-old female. The patient presented 100% involvement of the second metatarsal head, with a 6 × 2 mm defect, unresponsive to 16 months of conservative measures. A 7 mm × 3 mm pedicled metatarsal bone flap (PMBF) was obtained from the lateral proximal first metatarsal metaphysis, mobilized and pedicled distally. It was inserted at the dorsum of the distal metaphysis of the second metacarpal towards the center of the metatarsal head, reaching the subchondral bone. Initial favorable clinical and radiological results were maintained for over 36 months during the last follow-up. Based on the powerful vasculogenic and osteogenic properties of bone flaps, this novel technique could effectively induce bone revascularization and prevent further collapse of the metatarsal's head.

Percutaneous Fifth Metatarsal Osteotomy for Bunionette Deformity Without Fixation or Strapping: A Retrospective Study.

BACKGROUND: Bunionette deformity (BD) is a painful condition of the fifth metatarsal characterized by an osseous prominence and fifth toe varus deformity. The purpose of this study is to assess the clinical, functional, and radiographic outcomes of percutaneous distal metatarsal metaphyseal osteotomy (DMMO) without fixation or postoperative strapping of the foot. METHODS: A retrospective case series was performed on 111 patients (132 feet) with symptomatic BD who underwent percutaneous DMMO of the fifth metatarsal from September 2020 to January 2022 by an experienced minimally invasive surgeon. According to the Shimobayashi classification, we treated 1 type I deformity, 37 type II deformities, 52 type III deformities, 42 feet with type IV deformity, and no patient with a type V deformity. Ninety patients (81%) underwent unilateral osteotomy, and 21 (19%) had bilateral osteotomies. Most cases included other procedures including treatment of 114 associated deformities of the same feet: 68 bunions, 12 lesser metatarsal osteotomies (2-3-4 metatarsals), and 34 hammertoes (20 second hammertoes, 10 third hammertoes, 1 fourth hammertoes, 2 fifth hammertoes). Patient-reported clinical outcome measures, including the Foot Function Index (FFI) questionnaire, the visual analog score (VAS), and overall satisfaction were collected. Fourth-to-fifth intermetatarsal angle (IMA) correction, time to bone union, and complication rates were assessed in all patients. RESULTS: Mean follow-up was 24.1 months (range, 14-39 months). Both radiographic parameters and patient-reported outcome measures significantly improved after DMMO procedure. The average fourth-to-fifth IMA improved from 12.2 degrees, preoperatively, to 4.4 degrees, postoperatively (P < .001). Patient outcomes reflect the overall outcomes of the combined surgeries on a per-patient basis. Preoperatively, patients had a mean VAS score of 7.6, which improved to 0.6 at the last follow-up (P < .001). Furthermore, the average FFI significantly decreased from pre- to postoperation from 19.2 to 4.4, respectively (P < .001). Overall, 108 of 111 patients reported being satisfied with the outcomes of the procedure. Average bone union was achieved at 12.6 weeks postoperation, with a minimum of 12 and a maximum of 25 weeks. The complication rate was 1.5%, including 1 case of an asymptomatic cock-up deformity and 1 case of lateral fifth metatarsal shaft bone overhang pain, which resolved with an exostectomy. CONCLUSION: The results of this study of patients who had minimally invasive surgery from an experienced surgeon suggest that percutaneous DMMO of the fifth metatarsal without internal fixation or postoperative immobilization or strapping can be effective at improving radiographic alignment, pain, function, and overall satisfaction with minimal rates of complication. LEVEL OF EVIDENCE: Level IV, case series.

Successful treatment of advanced Freiberg's disease with a modified Weil osteotomy, 5-year follow up: A Pilot case series with a review of the literature.

INTRODUCTION: Treatment for Freiberg's disease is largely conservative. For severe disease and refractory cases, there are various surgical options. The purpose of this study was to report the 5-year clinical outcomes of a modified Weil osteotomy in the treatment of advanced Freiberg's disease. METHODS: Twelve patients (12 feet), with a mean age of 30.7 years (range 17-55), were treated with synovectomy and modified Weil osteotomy of the affected distal metatarsal head. There were 10 females and 2 males. Clinical outcomes were independently evaluated pre and postoperatively using the American Orthopaedic Foot and Ankle Society (AOFAS) scoring system and a subjective satisfaction score. Radiological union was evaluated postoperatively. Nine (75%) feet involved the 2nd metatarsal and 3 feet (25%) involved the 3rd metatarsal. According to the Smillie classification, 6 feet were Grade IV and 6 feet were grade V. RESULTS: No patients were lost to follow up and the mean follow-up time was 5.2 years (4-7). AOFAS scores improved from 48.1 + /- 7.4-88.9 + /- 10.1 postoperatively giving a mean improvement of 40.8 (p < 0.001). In total, 92% of patients were satisfied with their operation at latest follow-up, reporting excellent or good results. All patients had postoperative radiological union. One patient had a superficial postoperative infection that was successfully treated with oral antibiotics. CONCLUSION: Modified Weil osteotomy is an effective treatment for advanced Freiberg's disease with good outcomes and few complications.

A comparative analysis of clinical, functional and radiographic outcomes of patients with and without fusion between the first and second metatarsals after the lapidus procedure.

BACKGROUND: The aim of this study was to compare the clinical, functional and radiographic outcomes in patients who underwent the original Lapidus procedure (OLP) with fusion and undesired non-fusion between the first (M1) and second (M2) metatarsals. METHODS: A retrospective and comparative analysis of 29 patients (38 feet) who underwent the OLP was performed. They were divided in two groups: (1) 23 feet in which fusion occurred and (2) 15 with undesired non-fusion. Clinical and functional data were assessed with the VAS for pain, AOFAS, LEFS and SF-12. SF-12 comprises physical and mental health scales (PCS-12 and MCS-12). Radiographic parameters assessed were bony and soft tissue forefoot widths (BSFW), intermetatarsal-angle (IMA) and HV-angle (HVA). RESULTS: Separately, the groups presented significant improvements in all questionnaires (p < 0.001), except on MCS-12 (fusion p = 0.08 and non-fusion p = 0.27). When comparing both groups, patients with fusion had higher AOFAS scores (p < 0.05). Both groups presented the same improvements on BSFW, IMA and HVA (p = 0.09, p = 0.16, p = 0.52 and p = 0.63). CONCLUSION: Excellent results were observed, even when without fusion between M1 and M2. Patients who evolved with fusion between the M1 and M2 showed greater improvements in the AOFAS score. LEVEL OF EVIDENCE: III, retrospective comparative study.

Contrast administration via ultrasound-guided injection of the cranial tibial artery results in contrast enhancement of the soft tissues of the metatarsus in horses undergoing CT.

Delivery of mesenchymal stem cells (MSC) via intravascular techniques to treat diffuse and/or inaccessible soft tissue injuries has grown in popularity. The purpose of the current prospective, analytical pilot study was to utilize CT to validate this novel technique and provide additional evidence to support its use for injectate delivery to specific soft tissue structures. Of particular interest was the proximal suspensory ligament, which presents a challenging injection target. Six adult horses without lameness underwent CT of the distal hindlimbs. Scans were obtained prior to ultrasound-guided catheterization of the cranial tibial artery, in addition to early and delayed scans acquired following intra-arterial contrast administration. Region of interest analysis of the superficial and deep digital flexor tendons and suspensory ligament was used to assess contrast enhancement within these structures. Linear mixed models were used to determine statistical significance. Significant (P < 0.05) mean contrast enhancement was seen in all postinjection time points in all soft tissue structures of interest. This indicates that ultrasound-guided injection of the cranial tibial artery results in perfusion of injectate throughout the distal hind limb, including the major soft tissue structures of the metatarsus. This provides further support for this technique as a method of MSC delivery to multifocal or inaccessible injury of these structures, including the proximal suspensory ligament.

Foot morphology as a predictor of hallux valgus development in children.

An excess of body weight can produce morphological changes in the feet of children. The aim of this study was to assess the morphological differences of the foot in children based on their body mass index and to determine the risk factors for the development of a hallux valgus in childhood and adolescence. One Thousand Six Hundred Seventy-Eight children (5-17 years) were classified as group with obesity, overweight, and normal weight. Lengths, widths, heights and angles of both feet was measured with a 3D scanner. The risk of developing hallux valgus was calculated. Group with overweight and obesity presented longer feet (p = 0.00), wider metatarsals (p = 0.00) and wider heels (p = 0.00). Arch height was lower (p > 0.01) in the group with obesity, and the hallux angle was greater in the group with normal weight (p < 0.05). The relative risk of a lateral hallux deviation increases with age, foot length and heel width (Exp (B) > 1). Children with overweight and obesity had longer and wider feet. The arch height was higher in children with overweight, and lower in children with obesity. Age, foot length, and heel width could be risk factors for the development of hallux valgus, while metatarsal width and arch height could be protective factors. Monitorization of the development and characterization of the foot in childhood as a clinical tool could help professionals to early identify the patients presenting risk factors and prevent future deformities and other biomechanical conditions in adulthood by implementing protecting measures.

Risk Factors Associated with Plantar Necrosis following Tarsal Arthrodesis in Dogs.

OBJECTIVES: The aim of this study was to define landmarks of the intermetatarsal channel of the dorsal pedal artery and to assess whether damage to the dorsal pedal artery during metatarsal screw placement in dogs undergoing pan- and partial-tarsal arthrodesis (PanTA/ParTA) could be a mechanism in the development of plantar necrosis. STUDY DESIGN: This study was divided in to two parts: (1) ex-vivo anatomical study: 19 canine cadavers, (2) retrospective clinical study: 39 dogs. Cadaveric dissection documented the mean intermetatarsal channel position. Metatarsal screw position was evaluated on postoperative radiographs of dogs after PanTA or ParTA. Screw position, arthrodesis type and surgical approach were assessed for their impact on complications, including plantar necrosis. RESULTS: The mean proximal and distal extent of the intermetatarsal channel lies between 4.3% ± 1.9 and 22.8% ± 2.9 the length of metatarsal III (MTIII) respectively. The intermetatarsal channel lies within the most proximal 25% of MTIII in 95% of cases. At least one screw risked damaging the mean intermetatarsal channel position in 92% of dogs; 8% of these dogs went on to develop plantar necrosis. The mean screw position did not differ between ParTA cases with or without plantar necrosis (p > 0.05). CONCLUSION: Violation of the intermetatarsal channel is possible during metatarsal screw placement. Care should be taken when placing screws in the proximal 25% of the metatarsals, specifically avoiding exiting dorsally between MTII and MTIII and across the distal region of the intermetatarsal channel, where the perforating metatarsal artery passes interosseously, as damage may contribute to the aetiology of plantar necrosis.

Morphologic analysis of the 1st and 2nd tarsometatarsal joint articular surfaces.

Tarsometatarsal joint arthrodesis is used to treat a variety of injuries and deformities in the midfoot. However, the surgical technique has not been optimized, in part due to limited knowledge of morphologic features and variation in the related joints. Previous research has relied primarily on dissection-based anatomical analysis, but quantitative imaging may allow for a more sophisticated description of this complex. Here, we used quantitative micro-CT imaging to examine dimensions, distance maps, and curvature of the four articular surfaces in the first and second tarsometatarsal joints. Image segmentation, articular surface identification, and anatomic coordinate systems were all done with semi or fully automatic methods, and distance and size measurements were all taken utilizing these anatomic planes. Surface curvature was studied using Gaussian curvature and a newly defined measure of curvature similarity on the whole joint and on four subregions of each surface. These data show larger articular surfaces on the cuneiforms, rather than metatarsals, and define the generally tall and narrow articular surfaces seen in these joints. Curvature analysis shows minimally curved opposing convex surfaces. Our results are valuable for furthering knowledge of surgical anatomy in this poorly understood region of the foot.

Tibial torsion and pressures in the feet during walking: Implications for patterns of metatarsal robusticity.

OBJECTIVES: The Dmanisi Homo fossils include a tibia with a low degree of torsion and metatarsals with a pattern of robusticity differing from modern humans. It has been proposed that low tibial torsion would cause a low foot progression angle (FPA) in walking, and consequently increased force applied to the medial rays. This could explain the more robust MT III and IV from Dmanisi. Here we experimentally tested these hypothesized biomechanical relationships in living human subjects. MATERIALS AND METHODS: We measured transmalleolar axis (TMA, a proxy for tibial torsion), FPA, and plantar pressure distributions during walking in young men (n = 40). TMA was measured externally using a newly developed method. A pressure mat recorded FPA and pressure under the metatarsal heads (MT I vs. MT II-IV vs. MT V). RESULTS: TMA is positively correlated with FPA, but only in the right foot. Plantar pressure under MT II-IV does increase with lower TMA, as predicted, but FPA does not affect pressure. Body mass index also influenced plantar pressure distribution. DISCUSSION: Lower tibial torsion in humans is associated with slightly increased pressures along the middle rays of the foot during walking, but not because of changes in FPA. Therefore, it is possible that the low degree of torsion in the Dmanisi Homo tibia is related to the unusual pattern of robusticity in the associated metatarsals, but the mechanism behind this relationship is unclear. Future work will explore TMA, FPA, and plantar pressures during running.

Rate of tarsal and metatarsal bone mineral density change in adults with diabetes mellitus and peripheral neuropathy: a longitudinal study.

BACKGROUND: In people with diabetes (DM) and peripheral neuropathy (PN), loss of bone mineral density (BMD) in the tarsals and metatarsals contribute to foot complications; however, changes in BMD of the calcaneal bone is most commonly reported. This study reports rate of change in BMD of all the individual bones in the foot, in participants with DM and PN. Our aim was to investigate whether the rate of BMD change is similar across all the bones of the foot. METHODS: Participants with DM and PN (n = 60) were included in this longitudinal cohort study. Rate of BMD change of individual bones was monitored using computed tomography at baseline and 6 months, 18 months, and 3-4 years from baseline. Personal factors (age, sex, medication use, step count, sedentary time, and PN severity) were assessed. A random coefficient model estimated rate of change of BMD in all bones and Pearson correlation tested relationships between personal factor variables and rate of BMD change. RESULTS: Mean and calcaneal BMD decreased over the study period (p < 0.05). Individual tarsal and metatarsal bones present a range of rate of BMD change (-0.3 to -0.9%/year) but were not significantly different than calcaneal BMD change. Only age showed significant correlation with BMD and rate of BMD change. CONCLUSION: The rate of BMD change did not significantly differ across different foot bones at the group level in people with DM and PN without foot deformity. Asymmetric BMD loss between individual bones of the foot and aging may be indicators of pathologic changes and require further investigation. TRIAL REGISTRATION: Metatarsal Phalangeal Joint Deformity Progression-R01. Registered 25 November 2015, https://clinicaltrials.gov/ct2/show/NCT02616263.

Acute, isolated fractures of the metatarsal bones: an epidemiologic study.

INTRODUCTION: Although metatarsal fractures are common, the significance of previous epidemiologic studies is limited to specific fracture entities, subpopulations, or heterogeneous fracture aetiologies. The aim of the study was to assess the epidemiology of isolated metatarsal fractures in an adult population at a level-1 trauma centre. MATERIALS AND METHODS: Radiological and clinical databases were searched for a five-year period. Eligible were all patients with acute isolated metatarsal fractures over the age of 18 years with radiographs in two planes available. Stress fractures, injuries affecting Lisfranc joint stability, and concomitant injuries to other regions than the metatarsals were excluded. Data collection included general demographics, mechanism of injury, season of the trauma and fracture details. RESULTS: Out of 3259 patients, 642 patients met the inclusion criteria and were included for the analysis. The patients' mean age was 44.5 ± 18.9 years, 50.6% were female. 83.3% suffered an isolated, 16.7% multiple metatarsal fractures. Single metatarsal fractures occurred predominantly at the fifth metatarsal bone (81.3%), their frequency decreased with increasing age, with a seasonal peak during the summer. Patients suffering multiple metatarsal fractures were significantly older (51.6 ± 21.2 vs. 43.0 ± 18.1 years; p < 0.001) and the injury resulted significantly more often from a high-energy trauma (6.7% vs. 23.4%; p < 0.001). Multiple metatarsal fractures occurred evenly throughout all metatarsals but revealed a focus on female population with no seasonal differences. CONCLUSION: Single metatarsal fractures predominantly occurred at the fifth metatarsal bone and showed a seasonal, gender and age dependency. Multiple metatarsal fractures were homogeneously distributed between the different metatarsals with distinct age-dependent gender differences. LEVEL OF EVIDENCE: Level III.

Does metatarsus primus elevatus really exist in hallux rigidus? A weightbearing CT case-control study.

BACKGROUND: Elevated first metatarsal, Metatarsus primus elevatus (MPE), has been a topic of controversy. Recent studies have supported a significantly elevated first metatarsal in hallux rigidus on weight-bearing radiographs (WBR). However, conventional radiographs have limitations for accurate measurement. Our objective was to comparatively assess MPE and other variables which can affect the spatial relationship of the forefoot in the HR group compared to controls using weight-bearing CT (WBCT). METHODS: In this single-center, retrospective, case-control study, 25 patients (30 feet) with symptomatic HR and 30 controls were selected. WBCT parameters were measured by two independent investigators. Inter-observer reliabilities were assessed using intra-class correlation coefficients (ICCs). MPE was evaluated by measuring the direct distance between 1st and 2nd metatarsals. Independent t tests were performed to compare the two groups. A threshold of MPE to diagnose HR was calculated using the Receiver Operating Characteristic (ROC) curve. RESULTS: HR groups had increased hallux valgus angle (HVA) (8.52° in control vs 11.98° in HR) and MPE (2.92 vs 5.09 mm), decreased 1st metatarsal declination angle (21.09° vs 19.07°) 1st/2nd metatarsal declination ratio (87.45 vs 79.71) indicating elevated first metatarsal compared to controls. Dorsal translation of the first metatarsal at the first tarsometatarsal joint was observed in 21 (70%) patients of the HR group when defined as a step-off or discontinuation of the curvature along the first TMT joint. The threshold of MPE for diagnosis of HR was 4.19 mm with 77% sensitivity and 77% specificity. CONCLUSION: Our results confirmed a significantly elevated first metatarsal in the HR group compared to controls on WBCT. A MPE greater than 4.19 mm was found to be diagnostic for symptomatic HR. Significant number of patients in the HR group (70%) had dorsal translation of the first metatarsal at the first TMT joint which can contribute to increased MPE. CLINICAL RELEVANCE: The present study demonstrated significantly increased MPE in HR on WBCT and MPE greater than 4.19 mm on WBCT can be used as a diagnostic threshold for HR.

Brachymetatarsia: A Classification for Surgical Treatment.

Brachymetatarsia is a congenital osseous and soft tissue deformity of a ray(s) of the foot. Because there is no particular consensus of methodology of lengthening for brachymetatarsia, the authors introduce a comprehensive anatomic classification and a surgical guide to treatment of each classification type. This classification combines the number of the metatarsal(s) affected and the letter(s) indicating the type of brachymetatarsia deformity (A = axial deficiency of the metatarsal, B = bowing of the metatarsal, C = congruency of metatarsal phalangeal joint). This study reviewed of 300 brachymetatarsals in 166 patients. Fifty of the 166 (30%) patients had bilateral brachymetatarsia. Of the 300 metatarsals with brachymetatarsia, 64 (21%) were first metatarsals, 22 (7%) were second metatarsals, 28 (9%) were third metatarsals, 12 (4%) were fifth metatarsals, and 174 (58%) were fourth metatarsals. Classification types that were found was a total of 165 (55%) type A, a total of 6 (2%) type B, a total of 72 (24%) type AB, a total of 39 (13%) type AC, and a total of 18 (6%) type ABC. A total of 16 (10%) male and 150 (90%) female patients were evaluated. The mean preoperative amount of shortening of the metatarsal was 15 mm (range, 4-20 mm), as determined by the preoperative metatarsal parabola deficiency, equating to 30% of the preoperative metatarsal length. Brachymetatarsia is a complex congenital deformity which until now has not been critically analyzed. This study outlines a comprehensive brachymetatarsia classification system which provides an accurate diagnosis of the deformity and offers a surgical treatment algorithm.

Metatarsal head restoration versus dorsal closing-wedge osteotomy in the treatment of advanced-stage Freiberg's disease.

PURPOSE: Freiberg's disease is mostly characterized by osteonecrosis of second metatarsal head and is widely seen in adolescent women. Metatarsal head restoration technique is a novel surgical procedure intended to protect intact articular surface and regenerate avascular bone under cartilage. This study aimed to evaluate and compare the results and clinical outcomes of metatarsal head restoration technique with those of dorsal closing-wedge osteotomy technique in patients with advanced-stage Freiberg's disease. METHODS: In this retrospective study, 60 patients who were operated for Freiberg's disease were evaluated. Patients were divided into two groups as who underwent metatarsal head restoration and dorsal closing-wedge osteotomy. Groups were compared according to "American Orthopaedic Foot & Ankle Society score" (AOFAS), "visual analog score" (VAS) and passive "range of motion" (ROM) score. RESULTS: Thirty-two feet of 29 patients underwent metatarsal head restoration, while 33 feet of 31 patients were subject to dorsal closing-wedge osteotomy. Mean AOFAS score increased from 58.72 ± 6.89 to 89.35 ± 7.43 following metatarsal head restoration, while it increased from 54.13 ± 6.12 to 78.24 ± 6.54 after dorsal closing-wedge osteotomy. Mean VAS score decreased from 6.89 ± 1.18 to 1.33 ± 0.64 after metatarsal head restoration, while it decreased from 6.64 ± 0.92 to 2.71 ± 1.91 following dorsal closing-wedge osteotomy. Mean ROM increased from 12.25° ± 1.65 to 56.28° ± 2.77 after metatarsal head restoration, and it increased from 11.18° ± 0.66 to 47.65° ± 2.05 after dorsal closing-wedge osteotomy (all p < 0.05). In addition, postoperative mean AOFAS (p = 0.044), VAS (p = 0.041) and passive ROM (p = 0.034) scores improvement were found to be statistically significantly better in the metatarsal head restoration group. CONCLUSION: This study revealed that metatarsal head restoration is a safe and successful surgical technique. It leads to better results than dorsal closing-wedge osteotomy in patients with stages 3-4 Freiberg's disease. LEVEL OF EVIDENCE: III.

Maternal allogeneic cancellous bone graft for the treatment of osteitis along the physeal scar of the proximal metatarsus in a foal.

OBJECTIVE: To describe the treatment and outcome of a foal with a fresh allogenic cancellous bone graft after surgical debridement of a traumatic septic osteitis. ANIMAL: A neonatal Quarter Horse foal. STUDY DESIGN: Case report. METHODS: The foal sustained a traumatic laceration exposing the proximal third metatarsal bone. One week after surgical debridement and closure, radiographic signs of septic osteitis were noted along the physeal scar. The lesion was debrided, and antimicrobial therapy was implemented. The infection resolved but left a large defect in the metaphysis and epiphysis. Grafting was indicated to avoid pathologic fractures of the plantar and proximal cortices. Due to a discrepancy between defect size and the bone stock of the foal, an allogeneic cancellous bone graft was harvested from the dam's tuber coxae and used to fill the foal's defect. RESULTS: No adverse reactions to the graft were noted. After 1 month, the wound had healed. Radiographic examination was consistent with graft incorporation in the bone structure. The foal was sound at a walk and trot when examined at 6, 12, and 21 months. The bone's contour was even and its structure homogeneously radio dense. The surgical site of the mare healed without complications. CONCLUSION: Fresh allogenic cancellous bone grafting resulted in the healing of a large traumatic-septic bone defect in a foal, with an excellent functional and cosmetic outcome. For future use, compatibility testing should be considered prior to allogeneic bone grafting.

Freiberg`s disease of lesser metatarsals treated with bone grafting and autologous matrix induced chondrogenesis (AMIC) membrane - A series of 10 cases.

BACKGROUND: Freiberg's infraction is osteonecrosis of lesser metatarsal heads most commonly affecting adolescent females. They usually present with pain and swelling of the forefoot. MRI is useful investigation in the early diagnosis. It is a self-limiting disease and the main stay of treatment is non operative. Surgery is indicated in failed conservative management which include open debridement, cheilectomy, micro fracture, osteotomies and excision arthroplasty with varying success. METHODS: A retrospective analysis of ten patients with Freiberg`s disease of the lesser metatarsals treated with open debridement, microfracture, bone grafting and application of AMIC (Autologous Matrix induced Chondroplasty) membrane was carried out. The patients were followed up to five years and the outcome measures were scored using Manchester-Oxford Foot Questionnaire (MOxFQ) and EQVAS best health scores. RESULTS: The mean age was 42.7 years and follow-up time was 36.4 months. The most common site was second metatarsal, eight (80%) followed by third metatarsal, two (20%). The mean base line MOxFQ was 72.5 (95% CI- 45 ± 100) which improved to 42.5 (95%CI- 2.5 ± 82.5) at one year. The mean baseline VAS improved from 26.4(10.2 ± 42.6) to 30.3 (95%CI- 2.1 ± 58.5) at one year. The mean MOxFQ and VAS at the end of 36 months was 31.4(95%CI-6.6 ± 57.2) and47.3(4.3 ± 80.3) respectively. CONCLUSIONS: Open debridement of the Freiberg`s disease combined with microfracture of the defect, bone grafting and application of AMIC membrane shows reliable functional and radiological outcomes at short term follow up.

Transmetatarsal amputations in patients with diabetes mellitus: A contemporary analysis from an academic tertiary referral centre in a developing community.

Transmetatarsal amputation (TMA) involves the surgical removal of the distal portion of metatarsals in the foot. It aims to maintain weight-bearing and independent ambulation while eliminating the risk of spreading soft tissue infection or gangrene. This study aimed to explore the risk factors and surgical outcomes of TMA in patients with diabetes at an academic tertiary referral center in Jordan. Medical records of all patients with diabetes mellitus who underwent TMA at King Abdullah University Hospital, Jordan, between January 2017 and January 2019 were retrieved. Patient characteristics along with clinical and laboratory findings were analyzed retrospectively. Pearson's chi-square test of association, Student's t-test, and multivariate regression analysis were used to identify and assess the relationships between patient findings and TMA outcome. The study cohort comprised 81 patients with diabetes who underwent TMA. Of these, 41 (50.6%) patients achieved complete healing. Most of the patients were insulin-dependent (85.2%). Approximately half of the patients (45.7%) had severe ankle-brachial index (ABI). Thirty patients (37.1%) had previous revascularization attempts. The presence of peripheral arterial disease (P<0.05) exclusively predicted poor outcomes among the associated comorbidities. Indications for TMA included infection, ischemia, or both. The presence of severe ABI (≤0.4, P<0.01) and a previous revascularization attempt (P<0.05) were associated with unfavorable outcomes of TMA. Multivariate analysis that included all demographic, clinical, and laboratory variables in the model revealed that insulin-dependent diabetes, low albumin level (< 33 g/L), high C-reactive protein level (> 150 mg/L), and low score of Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC, <6) were the main factors associated with poor TMA outcomes. TMA is an effective technique for the management of diabetic foot infection or ischemic necrosis. However, attention should be paid to certain important factors such as insulin dependence, serum albumin level, and LRINEC score, which may influence the patient's outcome.

Arthroscopic removal of osteochondral fragments located within the condylar fossa of the third metacarpus/metatarsus in Thoroughbred yearlings.

OBJECTIVE: To describe an arthroscopic technique for the removal of osteochondral fragments located within the condylar fossa of the third metacarpal/tarsal bone. STUDY DESIGN: Retrospective study. ANIMALS: Thoroughbred yearlings (n = 11). METHODS: Osteochondral fragments located within the condylar fossa of the third metacarpal/tarsal bone identified during presale radiographic examination were removed via arthroscopy, assisted with ultrasonography in select cases. Complete fragment removal was confirmed by intraoperative radiography. RESULTS: Fragments were successfully removed using rongeurs following dissection of soft tissue attachments using a bipolar radiofrequency probe. No postoperative complications occurred. CONCLUSIONS: An ipsilateral arthroscopic and instrument portal coupled with ultrasound assistance and a radiofrequency probe allowed for successful removal of fragments located within the condylar fossa of the third metacarpal/tarsal bone. The technique allowed for the removal of the unstable osteochondral fragment and associated physical debris. CLINICAL SIGNIFICANCE: The described surgical technique enables the removal of osteochondral fragments located within the condylar fossa of the third metacarpal/tarsal bone with minimal disruption to the surrounding soft tissues.

[Effectiveness analysis of metatarsal mortise and tenon shortening osteotomy in treatment of macrodactyly in children].

Objective: To investigate the application and effectiveness of metatarsal mortise and tenon shortening osteotomy in the treatment of macrodactyly in children. Methods: The clinical data of 17 children with macrodactyly (18 feet and 27 toes) admitted between January 2018 and January 2020 were retrospectively analyzed. There were 12 males (12 feet and 18 toes) and 5 females (6 feet and 9 toes); the age ranged from 1 to 13 years, with a median age of 5 years. All children were treated with metatarsal mortise and tenon shortening osteotomy. Ten cases of single-segment metatarsals were shortened, 7 cases of 2-segment metatarsals, and 1 case of 3-segment metatarsals; involved 1 foot of single toe, 9 feet of 2 toes, 3 feet of 3 toes, 3 feet of 4 toes, and 2 feet of 5 toes. Five cases had lameness, and 1 case had limited walking with the big toes of both feet, and there was no obvious pain in all children. X-ray films showed that the involved phalanges were thickened and increased in 18 feet, and the deformity of the distal segment was heavier than that of the proximal segment in 13 feet, and the two were similar in 5 feet. The length of metatarsal shortening was 0.7-2.5 cm, with an average of 1.2 cm. The clinical healing of shortened metatarsal fractures in children was observed after operation, and the occurrence of related complications was recorded. Results: All 17 children were followed up 6-22 months, with an average of 14 months. All incisions healed by first intention. The osteotomy ends of 27 toes were clinically healed after operation, and the healing time was 4-8 weeks. No nonunion, fracture displacement, malunion, epiphyseal plate premature closure, and needle tract infection occurred. Conclusion: Metatarsal mortise and tenon shortening osteotomy is a good osteotomy method. It can improve the stability of the osteotomy end and increase the contact surface of the osteotomy end, which is conducive to the healing of the osteotomy end and is suitable for the treatment of macrodactyly.