[Bipolar dislocation of the first metatarsal bone]. / A propos d'une luxation bipolaire du premier métatarsien.

Simultaneous dislocation of the first cuneometatarsal joint and metatarsophalangeal joint is a rare injury. The case of a 22-year-old man is reported, but no previous cases have been reported in the literature. The treatment by closed reduction and pinning was very classical. Occasionally the reducibility of the metatarsophalangeal joint may be made more difficult by the interposition of a sesamoid bone. The simultaneous dislocation occurred because the injury was very severe. After 2 years, the function and mobility of the toe were normal, but radiographs revealed modifications of the Lisfranc joint.

[Value of a direct approach to the calcaneum]. / Intérêt d'une voie d'abord directe du calcanéum.

The authors describe an approach to the calcaneus: the incision follows the Achilles tendon and curves anteriorly between the lateral and plantar skin of the foot. The subtalar joint is opened using a Müller distractor, with one pin in the tibia and the other in the calcaneus. Sixty-one crush fractures of the thalamus were treated using this approach. There were 6 cases with skin problems; in 4 cases the skin necrosis was limited. This approach is useful in all cases: it provides excellent exposure of the subtalar joint, making a precise reduction of the fracture possible. When a distractor is used, varus of the calcaneus should first be reduced.

[Hallux valgus treated by shortening of the first phalanx with trans-epiphyseal impaction and adductor plasty. Apropos of 49 cases with 5-years follow-up]. / Hallux valgus traité par raccourcissement de la première phalange avec réenclavement dia-épiphysaire associé à la plastie de l'adducteur. A propos de 49 cas avec 5 ans de recul.

PURPOSE OF THE STUDY: 49 cases of hallux-valgus were treated by a shortening of the phalanx with impaction according to the technic described by Regnauld, associated with a plasty of the adductor. Patients were evaluated with a follow-up greater than 5 years. MATERIAL AND METHODS: 32 female and 5 male patients were treated. 63 per cent patients were between 30 and 60 years old. The preoperative average of metatarsus varus was 12 degrees 1. The length of first metatarsal was inferior to the second in 30 cases. The preoperative average of first phalange valgus was 30 degrees. Every operated foot had an Egyptian morphotype. Sesamoids were consistently dislocated. Associated lesion were: 19 flat feet, 10 round fore-feet, 9 clinodactylies treated during the same procedure. RESULTS: They were evaluated according 3 Groulier's criteria: the correction of deformation, static disturbances, and professional activities. The phalangeal valgus was corrected in 37 cases (72 per cent). 33 feet were painless (67 per cent). The dorsal flexion of the first toe was superior to 60 degrees in 38 cases (77 per cent). Metatarsus varus was consistently reduced. 2 permanent metatarsalgia and 4 plantar corns persisted. 76 per cent of operated patients were able to wear shoes normally with a normal perimeter of walking. At X-ray examination, the head of first metatarsal was unchanged in all cases. The joint space was normal in 39 cases (79 per cent). The base of first phalanx was normal in 25 cases (51 per cent). 37 feet had centered sesamoïds. In total, we noticed: 37 very good and good results (72 per cent), 8 moderate results (17 per cent), bad results (9 per cent). DISCUSSION: The operative technic gives a stable shortening of the first phalanx without material and allows the early weight bearing. The abductor of the great toe is a stronger muscle than adductor, allows rotational correction and the alignment of the first phalanx on the first metatarsal. We agree with criteria of bad prognosis proposed by Groulier: age, valgus flat foot, the duration and the importance of deformation, the presence of osteoarthritis. CONCLUSION: The abductor plasty and soft tissue operation contributes to the durable correction of hallux valgus. Shortening must preserve the vascularization of the proximal end of the phalangeal. This operation should be reserved for young patients, without signs of articular cartilage degeneration and having an Egyptian foot.

[Treatment of Morton neuroma by neurectomy. Apropos of 43 cases]. / Traitement du névrome de Morton par neurectomie. A propos de 43 observations.

PURPOSE OF THE STUDY: Morton's neuroma is a frequent cause of metatarsalgia. Its diagnosis is clinical but progress in medical imaging: ultrasound, evoked potentials and above all MRI allows an improvement of para-clinical diagnosis. MATERIAL AND METHODS: 48 neuromas were treated surgically between 1979 and 1990. That represents 46 feet in 43 patients. Female predominance was clear with an average age of 53 years. The follow-up period was 6 years and 10 months. 3 patients had multiple injuries. Medical treatment had been prescribed prior to surgery in 24 patients (15 had injections, 9 orthopedic shoe inserts and 5 both injections and inserts). The interval between the first symptoms and surgery was long since it was on average of 3 years and 6 months. The neuroma was located 36 times in the third interdigital space. The initial incision was plantar 11 times dorsal 32 times. Only neurectomies were performed. The neuroma was very large 9 times. 10 patients had treatment for other affections in the same operative time. RESULTS: At review, 41 feet were completely painless. Shoe wear was normal for 32 patients. 12 pulpar hypoesthesia and 7 commissural and pulpary hypoesthesia were noted. 3 of 11 patients operated by the plantar approach had a painful hyperkeratosic scar. DISCUSSION: None of our cases had preoperative MRI because our most recent case has 4 years of evaluation. At the present time the MRI could contribute to diagnosis owing to good tissular differentiation. The neurectomy led to a total disappearance of pain but hypoesthesia was frequent. The dorsal approach induces cutaneous complication. Neurolysis induces a sensitive postoperative deficit but recurrence occurs in 77 per cent of cases after neurolysis. CONCLUSION: Morton's neuroma is located essentially in the third interdigital space. Neurectomy is a simple operation that often leads to recovery.

[Subtalar arthrodesis for sequelae of calcaneal fractures. Apropos of 57 cases]. / Arthrodèse sous-astragalienne pour séquelles de fracture, du calcanéum. A propos de 57 cas.

PURPOSE OF THE STUDY: 57 subtalar arthrodesis for sequelae of calcaneal fractures were reviewed with a minimum follow up of 6 years 11 months. MATERIAL AND METHODS: Bone resection and interposition of bone grafts, stabilized by screws were used in 36 cases. Iliac crest grafts were used in 20 cases, cryopreserved grafts 15 times and local graft taken on the anterior tibial epiphysis once. No surgery was performed on the mid foot. RESULTS: Results were evaluated using the grading system described by Mestdagh with 33 good global results, 18 fair results and 6 poor results for a total of only 58 per cent of good global results. Of the 57 cases reviewed, 18 remained painful with a limited range of motion for inversion and eversion of the foot. In 18 patients monopodal weight-bearing was unstable. Residual oedema persisted in 5 patients. 16 patients continued to limp and 3 required the use of a crutch. 7 valgus and 3 varus deviations of the hindfoot were noted at follow up with poor tolerance of the varus when compared to exaggerated valgus. Podoscopic examination revealed increase anterior pressure zones responsible for metatarsalgia which was relieved by corrective shoe inserts in 10 patients. Radiographic evidence of fusion could be demonstrated in 55 cases. There was little or no repercussion on the tibio-talar joint. In the Chopart joint we noted 4 cases of osteoarthritis; there were 6 lesions in the talo-navicular joint and no repercussion in Lisfranc's joint. 16 complications of varying severity were noted with 2 nonunions following use of cryopreserved grafts. DISCUSSION: Subtalar arthrodesis for sequelae of traumatic lesion in the hindfoot gives good results in 2 cases out of 3. In our series, 26 per cent of the patients showed degenerative changes in the mid foot unlike the series published by Kempf. As Meary and Mestdagh noted, we found that residual varus or valgus deformity > 10 degrees was poorly tolerated as well as modifications > 20-30 degrees in the vertical ratio between the talus and the calcaneum in the horizontal plane. CONCLUSION: Subtalar arthrodesis is a useful technique giving good results in 2 out of 3 cases of traumatic sequelae in the hindfoot. Triple arthrodesis does not seem indicated when the talus and the calcaneus can be realigned before fusion. Talo-navicular arthrodesis, though more easily realized, requires blocking a normal joint in order to immobilize a painful joint.

[The Sixtine metatarsophalangeal prosthesis at first glance. Preliminary results in 74 cases]. / La prothèse métatarso-phalangienne Sixtine du premier rayon. Résultats préliminaires, à propos de 74 cas.

The Sixtine prosthesis is a metallic, hemiconical, flat concave, metatarsophalangeal interposition prosthesis, with a rim on the phalangeal end, with a lateral capsular fixation or a temporary fixation by axial pinning. Seventy-four cases using a Sixtine prosthesis were reviewed with a minimum follow-up of 2 years. The range of motion was improved (+12.4 degrees), as was the phalangeal valgus (18.2 degrees for 30.2 degrees), but weight bearing on the ventral side of the first toe was very often lost in spite of the complete preservation of the flexor hallucis brevis. The complication rate was 9.5% with 8% subluxations, which do not influence the final result. The comparison of patients who kept the prosthesis, and of patients in whom the prosthesis was systematically retrieved after one year, shows that the prosthesis may be left in place and that retrieval is only indicated in cases of complications or subluxation.