Is there a tolerance for extension of the first metatarsal after the Lapidus procedure? A clinical, functional, and hindfoot radiographic analysis.

PURPOSE: Based on the tripod concept of load distribution, our study aimed to evaluate whether a slight extension of first metatarsal (M1) that may occur after the Lapidus procedure (LP) could alter the radiographic measurements of the hindfoot and influence clinical and functional outcomes. METHODS: Twenty-five patients (27 feet) were reviewed. Hindfoot radiographic analysis was based on seven measurements. Clinical and functional outcomes were evaluated with self-reported questionnaires. Transfer metatarsalgia was also assessed. Correlation analysis was performed according to variations of the studied variables. RESULTS: The average extension of the M1 was 4.26 degrees (p < 0.001). None of the hindfoot radiographic measurements changed significantly (p = 0.13, p = 0.50, p = 0.19, p = 0.70, p = 0.11, p = 0.36, p = 0.83). Patients improved on most questionnaires (p < 0.001). None presented transfer metatarsalgia. No correlation between M1 extension and clinical and functional outcomes was found. CONCLUSION: Possibly there is a tolerance of M1 extension in which it does not alter the radiographic measurements of the hindfoot, overload the lesser metatarsals, or compromise clinical and functional outcomes.

Surgical Treatment of Metatarsalgia and Severe Instability of Lesser Metatarsophalangeal Joints.

The main object of this prospective cohort study was to compare surgical treatment options for primary metatarsalgia and the severe instability of lesser metatarsophalangeal joints. The outcomes of triple Weil osteotomy combined with direct plantar plate repair and triple Weil osteotomy, performed with proximal interphalangeal joint arthrodesis, are analyzed and compared. One hundred thirteen patients (117 feet) were enrolled in the study. They were split into 2 groups. In the first group, undergoing Weil osteotomy, combined with the plantar plate repair, good results, including complete pain reduction, elimination of hyperkeratosis, and American Orthopedic Foot and Ankle Society Score improvement, were achieved in 84.7% of the cases. The second group, where the combination of Weil osteotomy and proximal interphalangeal joint K-wire arthrodesis was used, demonstrated good results in 52.4% of the cases. Weil osteotomy, combined with the plantar plate repair, achieves better results in comparison to osteotomy, performed with the interphalangeal joint arthrodesis.

Differential Diagnosis of Metatarsalgia.

Lesser (or central) metatarsalgia is defined as pain in the forefoot under or around the lesser metatarsals and their respective metatarsophalangeal joints. Two common causes of central metatarsalgia are Morton's neuroma (MN) and plantar plate (PP) injury. Because both clinical and imaging features overlap, establishing the correct differential diagnosis may be challenging. Imaging has a pivotal role in the detection and characterization of metatarsalgia. Different radiologic modalities are available to assess the common causes of forefoot pain, so the strengths and weakness of these imaging tools should be kept in mind. It is crucial to be aware of the pitfalls that can be encountered in daily clinical practice when dealing with these disorders. This review describes two main causes of lesser metatarsalgia, MN and PP injury, and their differential diagnoses.

Comparison of modified Mitchell and Chevron osteotomies for hallux valgus.

BACKGROUND: Good clinical and radiological outcomes in mild-moderate hallux valgus (HV) can be achieved with Chevron osteotomy (CO) and modified-Mitchell osteotomy (MMO). The main goal of the present study was to compare the clinical and radiological outcomes after CO and MMO in HV. METHODS: The study included 45 patients, comprising 40 females with a mean follow-up of 87.5 ± 27.8 months. The outcome measurements of metatarsal length (MT1), HV angle (HVA), intermetatarsal angle (IMA), clinical outcomes, and metatarsalgia were evaluated pre- and postoperatively. RESULTS: No significant difference was determined between the MMO and CO groups in respect of metatarsalgia and AOFAS scores. The CO resulted in a significantly larger decrease in the MT1. The mean HVA and IMA correction was significantly greater after MMO than after CO. CONCLUSION: Since MMO may prevent MT1 shortening, which is a typical problem in the Mitchell osteotomy, MMO may be preferred over CO in patients with preoperative shortened first metatarsal.

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.

Correlation of first metatarsal sagittal alignment with clinical and functional outcomes following the Lapidus procedure.

BACKGROUND: The purpose of this study was to evaluate the effect of the variation of the first metatarsal (M1) sagittal alignment after the Lapidus procedure (LP) on clinical and functional outcomes, and transfer metatarsalgia. METHODS: Twenty-nine patients who underwent a LP, with a mean follow-up of 20 months, were reviewed. Radiographic, clinical and functional measurements were compared. Clinical and functional questionnaires applied were the visual analogue scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) scale, lower extremity functional scale (LEFS) and SF-12, which is divided in physical (PCS-12) and mental-health (MCS-12) scales. Radiographic analysis of M1 sagittal alignment was based on the first metatarsal declination angle (FMDA) and Meary Angle (MA). Intermetatarsal angle (IMA) and hallux valgus angle (HVA) were also measured. RESULTS: FMDA, IMA and HVA showed significant variation, but MA did not. Clinical and functional improvements were observed, except in MCS-12. No patient developed transfer metatarsalgia. A direct correlation was found between Δ-FMDA with Δ-PCS-12 and Δ-LEFS, meaning that excessive M1 dorsiflexion as measured by FMDA led to a decrease in PCS-12 and LEFS. Patients with Δ-FMDA of up to 3.2° of dorsiflexion were those who had significant improvements. CONCLUSION: Dorsiflexion of M1 can lead to decreased outcomes as measured by PCS-12 and LEFS. However, satisfactory outcomes can be obtained even with some dorsal deviation of the M1. LEVEL OF EVIDENCE: IV, retrospective case series.

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

BACKGROUND: Transfer 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. METHODS: The 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. RESULTS: Second 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. CONCLUSIONS: To 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.

Hallux valgus with second metatarsalgia: Is second metatarsal Weil osteotomy necessary?

BACKGROUND: The role of concomitant Weil osteotomy to address second toe metatarsalgia during hallux valgus correction is unclear. We aimed to critically analyse outcomes of an additional Weil osteotomy versus isolated Scarf osteotomy.in the management of hallux valgus and second metatarsalgia. METHODS: Patients with second toe metatarsalgia who underwent first metatarsal Scarf osteotomy for hallux valgus were enrolled retrospectively. Demographics, radiographic measurements and functional outcomes were assessed at baseline, 6-months and 2-years postoperatively. Between-group significance was established with Fisher exact test, Chi-square or Mann-Whitney U test. Within-group changes from baseline were assessed with paired t-test and Wilcoxon signed-rank test. RESULTS: 48 feet (34 isolated Scarf, 14 concomitant Weil osteotomy) were included. Both cohorts demonstrated significant improvements across all measures of functional outcome. However, patients with additional Weil osteotomy reported poorer short-term outcomes. CONCLUSION: Superiority of additional Weil osteotomy versus isolated Scarf osteotomy in addressing second toe metatarsalgia or improving functional outcomes was not demonstrated.

Sagittal Chevron Shortening Osteotomy With Lateral Wedge for Treatment of Lesser Metatarsal Overload: A Case Report.

Metatarsalgia is a common problem that refers to the tenderness and pain beneath the forefoot. Many metatarsal shortening osteotomies have been described to alleviate metatarsal overload; however, these osteotomies have been associated with a high complication rate of floating toe deformity. We present a case study that describes an innovative technique for the treatment of lesser metatarsalgia that allows for the repositioning of the metatarsal head, using a stable screw fixation designed to minimize the common complication of the floating toe.

Plantar pressure distribution in hallux valgus feet after a first metatarsal proximal crescentic osteotomy with a lesser metatarsal proximal shortening osteotomy.

BACKGROUND: Plantar 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. METHODS: The 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. RESULTS: The 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. CONCLUSION: FMPCO with LMPSO may improve the plantar pressure of the central forefoot comparable to healthy subjects.

Treatment of metatarsalgia based on claw toe deformity through soft tissue release of the metatarsophalangeal joint and resection of the proximal interphalangeal joint: Evaluation based on foot kinematics and plantar pressure distribution.

INTRODUCTION: This study investigated the effect of operative claw toe correction with release of the metatarsophalangeal (MTP) joint, repositioning of the plantar fat pad and resection of the proximal interphalangeal joint on foot kinematics, plantar pressure distribution and Foot Function Index (FFI). METHODS: Prospective experimental study with pretest-posttest design. The plantar pressure, 3D foot kinematics and the FFI of 15 patients with symptomatic claw toes were measured three months before and 12months after surgery. Mean pressure, peak pressure and pressure time integral per sensor and various foot angles were calculated for the pre- and posttest and compared to a control group (N=15). RESULTS: Claw toe patients have increased pressure under the distal part of the metatarsal head and less pressure under the proximal part of the metatarsal heads compared to healthy controls. After surgery, there was a redistribution of pressure, resulting in a significant decrease of pressure under the distal part and an increase under the proximal part of the metatarsal head, providing a more equal plantar pressure distribution. Except for some small areas under the forefoot, heel and toes, there were no significant differences in pressure distribution between the operated feet and controls. Small, but significant differences between the pre- and postoperative condition were found for the lateral arch angle, calcaneus/malleolus supination and tibio-talar flexion. The score on the FFI improved statistically significant. DISCUSSION: These findings imply that the present operative procedure results in a more equal distribution of the plantar pressure under the forefoot and decrease of pain and offers successful treatment of metatarsalgia based on claw toe deformity.

Impact of first metatarsal shortening on forefoot loading pattern: a finite element model study.

BACKGROUNDS: There has long been a consensus that shortening of the first metatarsal during hallux valgus reconstruction could lead to postoperative transfer metatarsalgia. However, appropriate shortening is sometimes beneficial for correcting severe deformities or relieving stiff joints. This study is to investigate, from the biomechanical perspective, whether and how much shortening of the first metatarsal could be allowed. METHODS: A finite element model of the human foot simulating the push-off phase of the gait was established. Progressive shortening of the first metatarsal from 2 to 8 mm at an increment of 2 mm were sequentially applied to the model, and the corresponding changes in forefoot loading pattern during push-off phase, especially the loading ratio at the central rays, was calculated. The effect of depressing the first metatarsal head was also investigated. RESULTS: With increasing shortening level of the first metatarsal, the plantar pressure of the first ray decreased, while that of the lateral rays continued to rise. When the shortening reaches 6 mm, the load ratio of the central rays exceeds a critical threshold of 55%, which was considered risky; but it could still be manipulated to normal if the distal end of the first metatarsal displaced to the plantar side by 3 mm. CONCLUSIONS: During the first metatarsal osteotomy, a maximum of 6 mm shortening length is considered to be within the safe range. Whenever a higher level of shortening is necessary, pushing down the distal metatarsal segment could be a compensatory procedure to maintain normal plantar force distributions.

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.

Central Metatarsalgia and Walking on Pebbles: Beyond Morton Neuroma.

OBJECTIVE: Central metatarsalgia relates to abnormalities of the second, third, and fourth metatarsals and their respective metatarsophalangeal joints. A variety of disorders present with central forefoot pain; they range from traumatic lesions (acute or chronic repetitive), inflammatory and infective disorders, nonneoplastic soft-tissue lesions, and benign tumors to malignant lesions. Patients often present with symptoms of localized pain in the forefoot that worsens on weight bearing (walking or running), which can be sharp or dull and often is perceived as a lump felt inside or underneath the foot and described as walking on a marble or pebbles. These patients are labeled as having central metatarsalgia and are further evaluated with ultrasound or MRI to establish a diagnosis. CONCLUSION: In this article, we review metatarsal and intermetatarsal lesions of the foot that present with central forefoot pain and a sensation of walking on pebbles, focusing on conditions mimicking Morton neuroma clinically or on imaging. We also briefly review some other plantar lesions and arthropathy that can present with awareness of lump underneath the foot.

Hyaluronic Acid Filler Injections Under the Metatarsal Heads Provide a Significant and Long-Lasting Improvement in Metatarsalgia From Wearing High-Heeled Shoes.

BACKGROUND: Metatarsalgia is a common overuse injury that may be caused by wearing high-heeled shoes. OBJECTIVE: To evaluate the decrease in metatarsalgia using a hyaluronic acid dermal filler. METHODS: A 6-month, open study was conducted in 15 subjects with metatarsalgia because of regularly wearing high-heeled shoes. Hyaluronic acid (20 mg/mL) with lidocaine hydrochloride (3 mg/mL) was injected under the metatarsal heads at baseline. Pain (on a 0-10 scale) under the metatarsal heads when walking in high heels was recorded in a weekly subject diary. RESULTS: At 6 months after injections, 5 subjects (33.3%) reported no metatarsalgia pain. For subjects with pain, they were able to wear high heels for significantly longer than before the injections (7.2 hours at 6 months vs 3.4 hours at baseline). Significant improvements from baseline were observed at Month 6 for time to onset of pain (3.5 hours longer), time between onset of pain and intolerable pain (1.9 hours longer), and pain sensation (-2.2 grades at onset and -3.8 grades at shoe removal). No adverse events were reported. CONCLUSION: Injection of hyaluronic acid filler to the forefeet provided a significant effective, long-lasting, and well-tolerated improvement in metatarsalgia because of wearing high-heeled shoes.

A Suture-Button Technique for Stabilization of the Plantar Plate and Lesser Metatarsophalangeal Joint.

We retrospectively evaluated the use of a suture-button technique to stabilize the plantar plate and lesser metatarsophalangeal joint (MTPJ) to alleviate pain and dysfunction due to failed digital surgery with lesser MTPJ dysfunction. Eight consecutive patients (8 feet, 13 rays) were studied, including 2 males (25%) and 6 females (75%). Their median age was 56.5 (range 25 to 72) years, and the median follow-up duration was 28 (range 21 to 36) months. Of the 8 patients, 7 (87.5%) underwent concomitant adjunct procedures. A 10-increment (equal intervals) pain score and the Bristol foot score (BFS) were used to assess subjective satisfaction and foot-related quality of life before and after surgery. The median preoperative pain score was 8 (range 5 to 10). Postoperatively, the median pain score was 0 (range 0), and the difference was statistically significant (p = .0106). The median preoperative and postoperative BFS was 53 (range 32 to 70) and 20 (range 18 to 34), respectively. The difference was also statistically significant (p = .018). One patient (12.5% of patients, 7.7% of rays) experienced wound dehiscence. All the patients indicated they would undergo the procedure again. From these findings, we believe the described suture-button technique is a useful method to stabilize the plantar plate and MTPJ after failed digital surgery.

Morton's interdigital neuroma of the foot: A literature review.

Morton's neuroma is one of the most common causes of metatarsalgia. Despite this, it remains little studied, as the diagnosis is clinical with no reliable instrumental diagnostics, and each study may deal with incorrect diagnosis or inappropriate treatment, which are difficult to verify. The present literature review crosses all key points, from diagnosis to surgical and nonoperative treatment, and recurrences. Nonoperative treatment is successful in a limited percentage of cases, but it can be adequate in those who want to delay or avoid surgery. Dorsal or plantar approaches were described for surgical treatment, both with strengths and weaknesses that will be scanned. Failures are related to wrong diagnosis, wrong interspace, failure to divide the transverse metatarsal ligament, too distal resection of common plantar digital nerve, an association of tarsal tunnel syndrome and incomplete removal. A deep knowledge of the causes and presentation of failures is needed to surgically face recurrences.

Percutaneous distal osteotomy of lesser metatarsals (DMMO) for treatment of metatarsalgia with metatarsophalangeal instability.

BACKGROUND: Clinical and radiological results of percutaneous distal metatarsal minimally invasive osteotomy (DMMO) of the lesser rays for surgical treatment of primary metatarsalgia due to plantar overpressure with metatarsophalangeal instability are described. The aim of this prospective study was to assess the efficacy, feasibility and safety of this minimally invasive surgical (MIS) technique, verifying the possibility to lower the complication rate related to surgical exposures, to reduce operating times with comparable functional and cosmetic results to those reported with traditional open procedures. METHODS: Hundred and six consecutive percutaneous distal osteotomies without fixation (DMMO) of the second, third or fourth metatarsal bones were performed in 57 patients (70ft) with a mean age at the surgery of 60.2 years (30-81) for treatment of metatarsalgia with metatarsophalangeal instability. Patients were clinically assessed with the AOFAS and Coughlin's Scores, the latter classifying the results in relation to the patient's subjective satisfaction. RESULTS: The mean follow-up was of 45.0±13.3months (24-68). All patients reported the disappearance or reduction of the pain that they had experienced prior to the operation around the metatarsal heads. The mean overall AOFAS score improved from 42.7±13.4 points (9-77) to 92.8±8.6 points (44-100) at the time of final follow-up. Patient subjective satisfaction according to Coughlin's classification was excellent in 62ft (88.6%), good in 7ft (10.0%), fair in 0ft and poor in one foot (1.4%). CONCLUSIONS: We consider the percutaneous distal lesser metatarsal osteotomy without fixation (DMMO) a reliable surgical option in metatarsalgia due to metatarsophalangeal instability in early stages as in grade I and II according to Coughlin classification.

[Metatarsalgia: Differential diagnosis and therapy]. / Metatarsalgie: Differentialdiagnose und Therapie.

Metatarsalgia refers to localized or generalized forefoot pain in the region of the metatarsal heads. Symptoms can be isolated or in combination with accompanying deformities occurring in the forefoot and/or hindfoot. Anamnesis and clinical investigation usually yield to the diagnosis, the underlying cause on the other hand is not always easy to identify. In the foreground of the treatment is the exhaustion of conservative forms of therapy to minimize the symptoms of local pressure increase and callus under the metatarsal heads. In addition, various surgical methods are available, such as corrective osteotomy of the metatarsale bone, soft tissue interventions and the correction of associated deformities. The indications for surgical intervention should be made with caution in order to avoid failures and complaints persisting after surgery. The most common problems are an inadequate indication for surgery, technical problems and insufficient postoperative treatment.

Technique tip: Simultaneous first metatarsal lengthening and metatarsophalangeal joint fusion for failed hallux valgus surgery with transfer metatarsalgia.

BACKGROUND: Failed hallux valgus surgery may result in residual or recurrent hallux valgus, and as well transfer metatarsalgia. The present technical tip concerns the combination of fusion of the first metatarsophalangeal (MTP) joint and lengthening of the first metatarsal (MT) through a scarf osteotomy. MATERIALS AND METHODS: Six patients underwent the presented technique, all for the indication of failed hallux valgus surgery with shortening of the first MT and degenerative changes in the 1st MTP joint. RESULTS: Follow-up at six months revealed all patients had complete healing of the osteotomy and arthrodesis sites. They were all asymptomatic and fully active, completely satisfied with the outcome. CONCLUSIONS: Combined fusion of the first MTP joint and lengthening of the first MT through a scarf osteotomy results in an excellent outcome in patients with failed hallux valgus surgery with shortening of the first MT and degenerative changes in the 1st MTP joint.