Congenital Generalized Lipodystrophy in a Division 1 Female Sprinter.

ABSTRACT: A 21-year-old African American Division 1 female sprinter presented with 3-weeks history of right great toe and forefoot pain, fatigue, and a 30-day continuous menstrual cycle despite implanted etonogestrel (Nexplanon) inserted 3 years prior. An magnetic resonance imagine (MRI) identified likely stress fracture of the second metatarsal base with a diffusely low T1 signal indicating hyperactive red marrow. Due to persistent pain, a follow-up MRI was ordered 6 months later and indicated serous atrophy of the bone marrow, prompting a further metabolic workup notable for triglycerides exceeding 4000 mg/dL and a hemoglobin A1c of 10.9%. This case highlights the manifestation of a rare congenital lipodystrophy that initially presented as a relatively classic stress fracture and metrorrhagia in a female athlete.

Operative Management of Y-Shaped Metatarsal with Biphalangeal Sixth Toe.

BACKGROUND: In the literature, there is no consensus regarding the surgical management of postaxial polydactyly, and few cases of polymetatarsia with polydactyly have been reported. Treatment of the complete deformity will prevent further foot and gait disorders. OBJECTIVE: To identify literature relevant to the operative management of Y-shaped metatarsal with biphalangeal sixth toe and related skin and wound care to improve surgical treatment protocols from a clinical experience perspective. DATA SOURCES: The authors searched several electronic databases in December 2022 for articles related to postaxial polysyndactyly in the feet and polymetatarsia. Databases searched included PubMed, SciELO, ScienceDirect, Cochrane Database of Systematic Reviews, and Google Scholar gray literature. STUDY SELECTION: Two independent researchers conducted the searches and read the article titles and abstracts. Studies were included if they were narrative reviews, case studies, or observational studies; written in English or Spanish; and published between 2012 and 2022. Nonhuman studies were excluded. Studies that met the inclusion criteria were fully evaluated. Disagreements between reviewers were resolved by consensus, and when there was no consensus, a senior researcher was consulted. DATA EXTRACTION: The following data were extracted from the included studies using a standardized form: author and year of publication, study type, number of participants, sex, polydactyly location, polymetatarsia, type of polydactyly, participants' history of hereditary associated diseases or malformations, treatment, removal criteria, and timing of surgery. DATA SYNTHESIS: Authors evaluated 11 studies of postaxial polydactyly that included a total of 153 participants (64 men, 89 women). They also document their clinical experience with a surgical technique used in cases of bilateral postaxial polydactyly of the foot with a Y-shaped metatarsal with biphalangeal sixth toe. CONCLUSIONS: Surgical correction with lateral removal of the sixth toe is a resolutive treatment to improve the functionality of the foot, its aesthetic appearance, and the patient's quality of life. Case-specific treatment should be applied and tailored to meet the individual needs. The biomechanics of gait and shoe problems in these patients improve with surgical treatment, without presenting secondary aesthetic problems in skin care.

Metatarsal lengthening by distraction osteogenesis for brachymetatarsia in paediatric patients: is it safe and effective?

PURPOSE: The primary aim is to assess the efficacy of the surgical callus distraction technique of the metatarsus in paediatric patients. Secondary objectives are to assess complications and treatment duration. We have also described the details of our surgical technique. MATERIALS AND METHODS: A case series review of paediatric patients who had metatarsal lengthening at our unit between 2014 and 2022. Patient demographics, duration of time in frame, complications and metatarsal length achieved were recorded. The AOFAS Midfoot and the MOXFQ were taken pre-operatively and at final follow-up. RESULTS: Sixteen metatarsals in 8 patients (14 feet) underwent lengthening between 2014 and 2022 using the MiniRail OrthoFix 100 (Orthofix Medical Inc, Lewisville, TX, USA). The mean age was 13.3 (12-17) years. The average duration between surgery and implant removal was 5.2 months. According to Paley's classification, there was one obstacle encountered in a patient who required a revision of their osteotomy and one problem in another patient who had an infected metatarsophalangeal joint stabilising k-wire treated with oral antibiotics. The Mean AOFAS Midfoot score improved from 53.10 to 86.40 (p < 0.0001) and the Mean MOXFQ improved from 32.5000 to 12.1250 (p < 0.05); these were statistically significant. CONCLUSION: Gradual metatarsal lengthening using the MiniRail external fixator is a safe and effective method to treat brachymetatarsia in paediatric patients. This preliminary report describes and supports metatarsal lengthening in appropriate patients. Holistic care in terms of a pre-operative assessment, psychological support and preparation for the extended rehabilitation period are vital.

Os Intermetatarseum: A Rare Variation of Great Relevance / Os Intermetatarseum: Una Rara Variación de Gran Relevancia

SUMMARY: The os intermetatarseum is an accessory bone located in the foot, usually between the first 2 metatarsals and the cuneiform bone. It can be presented as free, articulated or in a fused fashion. It is a very unusual variation found in less than 13 % of the population. A 27-year-old patient presented to the emergency service due to an ankle lesion. Physical exam showed pain and limited range of motion while supporting partial load. Radiographic imaging showed a bony trace near the base of the first and second metatarsals, diagnosed as the os intermetatarseum. Formation of this supernumerary bone begins as a separate ossification center. Most cases are asymptomatic; however, compression of the deep peroneal nerve branches by the os intermetatarseum can lead to pain. Some authors suggest that the presence of this bone may cause hallux valgus. The intermetatarseum can lead to diagnostic confusion, mainly related to Lisfranc fracture. Its origin is still little understood.

El os intermetatarseum es un hueso accesorio ubicado en el pie, generalmente entre los 2 primeros metatarsianos y el hueso cuneiforme. Puede presentarse de forma libre, articulada o fusionada. Es una variación muy inusual que se encuentra en menos del 13 % de la población. Paciente de 27 años que acude a urgencias por lesión en tobillo. El examen físico mostró dolor y rango de movimiento limitado mientras soportaba una carga parcial. Las imágenes radiológicas mostraron un rastro óseo cerca de la base del primer y segundo metatarsianos, diagnosticado como os intermetatarseum. La formación de este hueso supernumerario comienza como un centro de osificación separado. La mayoría de los casos son asintomáticos; sin embargo, la compresión de las ramas profundas del nervio fibular en el espacio intermetatarsiano puede provocar dolor. Algunos autores sugieren que la presencia de este hueso puede provocar hallux valgus. El hueso intermetatarsiano puede llevar a confusión diagnóstica, principalmente relacionada con la fractura de Lisfranc. Su origen aún es poco comprendido.

The Prevalence of Bunions in the Setting of Brachymetatarsia.

Brachymetatarsia is caused by premature closure of the physis and is characterized by a short metatarsal. Additional foot conditions may exist in patients presenting with brachymetatarsia, such as hallux valgus (HV). A retrospective study was performed to evaluate the prevalence of HV and brachymetatarsia in the ipsilateral foot. Ninety-seven feet with congenital brachymetatarsia were reviewed in a multi-study cohort of 66 patients who underwent surgical correction between January 2005 and August 2020 at a single institution. The group was comprised of 61 females and 5 males, with a mean age of 27 years. HV deformities were verified with standardized anteroposterior radiographs. HV was present in 29 of 97 feet for a prevalence of 30% in the feet with brachymetatarsia. Our results demonstrate a 30% prevalence of HV associated with brachymetatarsia. This information is helpful for foot and ankle surgeons managing brachymetatarsia to determine appropriate conservative or surgical management of this condition.

Subacute two stage metatarsal lengthening with gradual distraction for brachymetatarsia: A consecutive case series and literature review.

BACKGROUND: This study examined the functional and clinical outcomes of subacute two stage metatarsal lengthening with gradual distraction for brachymetatarsia. This technique was developed to overcome the disadvantages of one-stage metatarsal lengthening and gradual distraction. METHODS: Four feet of three patients with congenital brachymetatarsia underwent subacute two stage metatarsal lengthening with gradual distraction. Pain, function, and alignment were assessed preoperatively and at follow-ups using the American Orthopaedic Foot and Ankle Society (AOFAS) lesser metatarsophalangeal-interphalangeal scale, and any complications were recorded. RESULTS: The patients were followed up for a mean of 18.1 ± 6.9 (range, 12.6-28.1) months. The mean metatarsal length gain was 15.2 ± 3.2 (range, 12.1-18.5) mm, and the corresponding percent increase was 32.5 % ± 7.0 % (range, 25.7-41.1 %). The mean AOFAS score (0-100) was 97.5 ± 5.0 at the final follow-up. The external fixator index was 10.2 ± 1.5 (range, 8.1-11.6) days/cm. None of the patients experienced metatarsophalangeal stiffness, subluxation or dislocation of the metatarsophalangeal joint, loss of correction, pin tract infection, delayed union, nonunion, or angular deformities. CONCLUSION: Subacute two stage metatarsal lengthening with gradual distraction is a reliable alternative treatment for brachymetatarsia.

The Role of the Shortened Proximal Phalanx in the Setting of Brachymetatarsia.

Brachymetatarsia is a condition in which a metatarsal bone does not grow out to full length. This is caused by premature physeal closure. The proximal phalanx associated with the shortened metatarsal helps achieve the natural parabola of the foot. A hypoplastic proximal phalanx is a common finding in patients with brachymetatarsia. The goal of this study was to determine the length of the proximal phalanx in the setting of brachymetatarsia, and how much the shortening is attributed to the clinically smaller toe. We performed a retrospective study to evaluate the length of the proximal phalanx in the shortened ray. After the metatarsal was brought out to the desired length of correction, the proximal phalanx was measured on radiographs. Ninety-seven feet with congenital brachymetatarsia were reviewed in a cohort of 66 patients who underwent surgical correction between January 2005 and February 2020 at a single institution. The group was comprised of 61 females and 5 males, with a mean age of 27.5 years. The average length of the proximal phalanx associated with the affected metatarsal was noted to be 18.9 ± 3.83 mm for males and 15.6 ± 4.02 mm for females. Our results indicate the shortened proximal phalanx is 5 mm shorter when compared to normal population and is a contributing factor to the shortened clinical appearance of the digit in brachymetatarsia. Treating surgeons should be aware of this to better educate patients on the influence of the digit on the overall shortening seen in cases of brachymetatarsia.

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.

Braquimetatarsia: propuesta de tratamiento en base a técnicas de alargamiento: a propósito de dos casos / Brachymetatarsia: treatment proposal based on lengthening techniques: about two cases / Braquimetatarsia: proposta de tratamento baseada em técnicas de alongamento: sobre dois casos

Braquimetatarsia es el acortamiento anormal de uno o más metatarsianos. Tiene una incidencia de 0.02%-0.05% predominando en mujeres de 25 a 1. En un 72% puede ser bilateral. La etiología no es clara pero se plantea el cierre prematuro de la fisis dando un retardo en el crecimiento. La mayoría de las veces presenta síntomas causados por alteración en la mecánica de la parábola metatarsal como dolor e hiperqueratosis. Puede existir metatarsalgia y agregar en la evolución desviaciones digitales adicionales. El principal motivo de consulta es estético. El objetivo del reporte es mostrar dos técnicas quirúrgicas y los resultados clínicos correspondientes usando el score AOFAS, además de los resultados imágenológicos con hasta 5 años de seguimiento. Se describen dos pacientes y se analizan dos técnicas quirúrgicas diferentes para alargar los metatarsianos. Se trata de alargamientos agudos con interposición de injerto intercalar, en un caso mediante el procedimiento de Sandro Gianini con injerto de cresta ilíaca y en el otro con injerto de metatarsiano adyacente con modificación de la longitud del segundo y tercer metatarsiano restituyendo en ambos casos la parábola metatarsal. Obtuvimos buenos resultados al igual que series numerosas pudiendo recomendarse en casos similares.

Brachymetarsal is the abnormal shortening of one or more metatarsals. It has an incidence of 0.02%-0.05%, predominantly in women from 25 to 1. In 72% it can be bilateral. The etiology is not clear, but premature closure of the physis is suggested, giving growth retardation. Most of the time it presents symptoms caused by an alteration in the mechanics of the metatarsal parabola, such as pain and hyperkeratosis. There may be metatarsalgia and add additional digital deviations in the evolution. The main reason for consultation is aesthetic. The objective of the work is to show the surgical technique and the clinical results using the AOFAS score, in addition to the imaging results with up to 5 years of follow-up. Two patients are described and two different surgical techniques to lengthen the metatarsals are analyzed. These are acute lengthenings with intercalary graft interposition, in one case using the S.Gianini procedure with an iliac crest graft and in the other with an adjacent metatarsal graft with modification of the length of the second and third metatarsals, restoring in both cases the metatarsal parabola. We obtained good results. results as well as numerous series and can be recommended in similar cases.

Braquimetatarsal é o encurtamento anormal de um ou mais metatarsos. Tem incidência de 0,02%-0,05%, predominantemente em mulheres de 25 a 1 ano. Em 72% pode ser bilateral. A etiologia não é clara, mas sugere-se o fechamento prematuro da fise, causando retardo de crescimento. Na maioria das vezes apresenta sintomas decorrentes de uma alteração na mecânica da parábola metatarsal, como dor e hiperqueratose. Pode haver metatarsalgia e adicionar desvios digitais adicionais na evolução. O principal motivo da consulta é a estética. O objetivo do trabalho é mostrar a técnica cirúrgica e os resultados clínicos utilizando o escore AOFAS, além dos resultados de imagem com até 5 anos de seguimento. Materiais e métodos: São incluídos dois pacientes e analisadas duas técnicas cirúrgicas diferentes para alongar os metatarsos. São alongamentos agudos com interposição de enxerto intercalar, em um caso utilizando a técnica de S. Gianini com enxerto de crista ilíaca e no outro com enxerto de metatarso adjacente com modificação do comprimento do segundo e terceiro metatarsos, restaurando em ambos os casos o metatarso parábola. Obtivemos bons resultados, bem como inúmeras séries, podendo ser recomendados em casos semelhantes.

Treatment of Cleft Foot Deformity using Fish Mouth Incision and Suture-Button in Paediatric Foot: A case report.

Cleft foot is a congenital anomaly characterised by absence of the metatarsal bones and phalanges. It is commonly seen in children with ectrodactyly-ectodermal dysplasia-clefting syndrome ranging from a median cleft up to the mid metatarsals to a deep cleft up to the tarsal bones. Surgical treatment in the form of cleft closure, excision of the rudimentary metatarsal bone and cross K-wire fixation of metatarsal bones have been tried for the management of such cases. We report a one-year-old child who presented to the paediatric orthopaedic clinic at a medical college in New Delhi, India, in 2018 with type III cleft foot with four metatarsals. The patient was treated with a suture-button system using three transverse tunnels in the second and third metatarsal bones in order to bring them closer together. A satisfactory outcome was achieved with normal fitting footwear.

Callus distraction with external fixator for the treatment of congenital brachymetatarsia of the fourth ray.

BACKGROUND: Brachymetatarsia is a rare abnormality of the foot which occurs most frequently in the first and fourth metatarsals. The aim of this study was to evaluate the efficacy of gradual metatarsal lengthening by external fixator for treatment of brachymetatarsia of the fourth ray. The hypothesis was that with external fixation it would be possible to achieve the desired length of the metatarsal with a low rate of complications. Secondarily, in cases requiring a greater amount of correction, it was hypothesized that an opportune rate of bone consolidation would be achievable using a traditional oscillating saw without predrilling or use of a cold osteotome. METHODS: Between 2013 and 2016, 12 eligible patients and 13 feet underwent gradual metatarsal lengthening by an external fixator (MiniRail System M103, Orthofix) due to brachymetatarsia of the fourth ray. Mean age at surgery was 24.5±5.3 years (range 19-36), with mean follow-up of 22.3±8.3 months. Clinical evaluation was performed with the AOFAS lesser metatarsophalangeal-interphalangeal (MTP-IP) score. Radiographic assessment was performed on follow-up using non-weightbearing dorsoplantar foot radiographs. RESULTS: The mean AOFAS lesser MTP-IP score improved from a preoperative score of 76.6±7.1 points (range 62-85 points) to a postoperative score of 90.3±3.0 points (range 86-95 points). The average amount of lengthening was 16.8±3.9mm (range 8-22mm). Mean shortening, final lengthening, Healing Index, period of treatment, and complications are also reported. The operative technique is described. CONCLUSIONS: Gradual metatarsal lengthening with external fixator is an effective treatment for brachymetatarsia and can restore forefoot anatomy with good clinical outcomes, a low rate of morbidity and complications in selected cases. Particular attention should be given when treating patients with shortening >20mm.

Forefoot malformations, deformities and other congenital defects in children.

Congenital pathologies of the forefoot encompass two broad entities with vastly different treatments and prognosis: malformations, which occur during the embryonic period and cause anatomical defects, and deformations, which occur during the fetal period on a foot that is configured normally. These deformities are more easily cured when they occur later during the fetal period. When the anomaly is bilateral, a genetic origin must be considered. There are two main entities under the term "deformity": metatarsus adductus and skewfoot (aka "Z"-foot or serpentine foot). Within malformations are brachydactyly (transverse defects), longitudinal defects, syndactyly, polydactyly, clinodactyly and macrodactyly. Among other forefoot abnormalities are hallux valgus, which rarely presents in congenital form, and for which conservative treatment is sometimes sufficient. Also in this group are sequelae of amniotic band constriction, forefoot anomalies secondary to the treatment of congenital pathologies (talipes equinovarus and congenital vertical talus) and nail-related pathologies (ingrown toe nail and incorrect nail position).

Does Hallux Valgus Exhibit a Deformity Inherent to the First Metatarsal Bone?

Hallux valgus is a common condition, and it still poses some challenges. The identification of factors associated with the development of the deformity is of paramount importance in obtaining a full correction of the disorder. Hallux pronation is one of the frequently found components, especially in larger deformities, but the cause and exact location of this condition are not fully understood. The aim of the present study was to investigate whether there is a rotational deformity inherent to the first metatarsal bone. A case-control study was conducted on patients with and without hallux valgus who were subjected to computed tomography with multiplanar reconstruction. Statistical analysis was performed by means of a mixed model adjusted for foot and gender to compare metatarsal rotation between cases and controls. Correlations between numerical quantitative measurements were investigated by means of Pearson's correlation coefficient obtained in a linear mixed model. A total of 82 feet (tests) were analyzed in the hallux valgus group and 64 feet (tests) in the control group (N = 146). The hallux valgus group was significantly different from the control group (p< .001). Mean metatarsal bone rotation was 15.36° (range 1.65° to 32.52°) in the hallux valgus group and 3.45° (range -7.40° to 15.56°) in the control group. The difference between the means was 11.9° (confidence interval 9.2° to 14.6°). In conclusion, patients with hallux valgus exhibited increased exclusive bone rotation of the first metatarsal toward pronation compared with the population without this condition.

Nonsyndromic Massive Tarsal and Tarsometatarsal Coalitions in a Young Female.

Tarsal coalition is an abnormal connection between 2 or more tarsal bones, with the most common sites being between the talus and the calcaneus and between the navicular and the calcaneus. The occurrence of multiple and massive tarsal coalitions is rare. We describe a rare case of nonsyndromic bilateral tarsal coalition involving most of the tarsal bones and extending to the metatarsal bones in a 4-year-old female. The condition was not painful and did not affect her gait. The main concern was the abnormal shape of her feet. Tarsal coalition can occur as an isolated anomaly or in association with other congenital disorders, usually presenting around the age of 12 years. The coexistence of nonsyndromic bilateral multiple tarsal coalitions is seldom reported. Regardless of the presentation, treatment is not indicated in cases of asymptomatic tarsal coalition. Our patient had a unique presentation of tarsal coalition, involving both the tarsal and tarsometatarsal bones. To our knowledge, this is the first report of this type of presentation.

Complications of distraction osteogenesis in brachymetatarsia: Comparison between the first and fourth brachymetatarsia.

BackgroundRecently, distraction osteogenesis has been widely used to treat brachymetatarsia. However, few papers have compared complications associated with this treatment. The purpose of the present study was to compare the complications between the first and fourth brachymetatarsia treated by distraction osteogenesis. MethodsWe performed distraction osteogenesis to 83 metatarsals in 41 patients between 1999 and 2012. A total of 30 metatarsals received treatment for the first metatarsal (Group A) while 53 metatarsals received treatment with the fourth metatarsal (Group B). ResultsThe complication rate in Group A (40%) was higher than that in Group B (18.9%). Those who had high percentage of lengthening gain were more likely to have complications. A cut-off value for lengthening gain developing complication was 41.3%. ConclusionComplication incidence after distraction osteogenesis was increased when lengthening gain was more than 41.3% for brachymetatarsia. In the 1st metatarsal lengthening, the most common complication was stiffness. In contrast, complications of the 4th metatarsal lengthening were pin-track infection and angular deformity.

Modified Lindgren-Turan Osteotomy for Hallux Valgus Deformity - a Review of 60 Cases.

PURPOSE OF THE STUDY To evaluate the clinical and radiological results of a new modification of relatively less-known Lindgren-Turan osteotomy technique in HV deformity that is performed by combining bunionectomy and capsuloplasty. MATERIAL AND METHODS 60 feet of 52 patients with moderate and heavy deformity who were operated between 2009 and 2014 were included in the study. The patients had clinically severe pain, did not respond to at least 6-month conservative treatment and had moderate and severe deformity before Hallux valgus angle (HVA), intermetatarsal angle (IMA), distal metatarsal joint angle (DMAA), proximal phalangeal joint angles (PPAA) and shortening amount in the first metatarsus were measured through preoperative and follow-up radiography. Clinical evaluations were conducted on all patients using American Orthopedic Foot and Ankle Society's (AOFAS) and visual analog scale (VAS). Data of the radiological and clinical evaluations in preoperative and follow-up periods were compared statistically. Statistical significance was accepted at p < 0.05. RESULTS 42 (76.1%) and 10 (23.9%) of 52 patients were female and male, respectively. Mean age of the patients was 50.9±15.52 years. Mean follow-up period of the patients was 43.3±2.1. Preoperative and last measurements: HVA: 36.34°±6.36° - 15.6°±2.83°, IMA: 12.62°±2.24° - 5.83°±1.32°, DMAA: 16.3°±3.45° - 10.3°±2.24°, PFAA: 7.24°±1.32° - 6.12°±0.84° (p < 0.001). Shortness of first metatarsus was measured to be 5.94±1.84 mm. Mean VAS values of the patients which was 8.6±0.4 before the operation was detected as 0.8±0.04 after follow-up (p < 0.001). AOFAS score of the patients which was 42.4±5.3 before the operation was found to be 88.9±7.6 (p < 0.001). All patients started to work again within 5.22±1.7 weeks. Union was completely seen along osteotomy line in all cases. Three patients had screw extraction. Two patients had superficial wound infection. DISCUSSION Capsule plication which we apply with osteotomy as part of our surgical procedure is a significant point in correcting deformity and raising stability. First metatarsophalangeal rigidity risk can be avoided with a controlled plication in operation and by giving the final decision after testing. Such flexibility shows that soft tissue contracture is not the main factor of deformity, so lateral release is not indicated. Thus, our opinion is that digital nerve damage and extra scar are avoided during lateral release. The osteotomy we applied which is extraarticular and subcapital, and protection of racket-shaped capsule cannot be attributed to finding no AVN case. CONCLUSIONS Modified Lindgren-Turan surgical procedure which is applied with capsuloplasty and bunionectomy is an effective and reliable method in treatment of moderate and severe HV deformities. It is recommended as a satisfactory option in HV treatment due to its ease in surgery, use of single incision and perfect clinical and radiological long-term results. Key words:hallux valgus, osteotomy, Lindgren-Turan, capsuloplasty, capsulorrhaphy, bunionectomy, plication.

Longitudinal Epiphyseal Bracket of the First Metatarsal Bone: Three Case Reports and a Review of the Literature.

Longitudinal epiphyseal bracket (LEB) is a rare bone dysplasia of the tubular bones. Owing to an abnormal secondary ossification center, the affected bones can develop progressive shortening and angular deformity. The aim of our study was to provide an overview of the reported data regarding epidemiology and surgical procedures available for LEB of the first metatarsal bone in a pediatric population combined with a small case series. We report a retrospective case series of 3 nonsyndromic pediatric patients with different ages and with confirmed dysplasia of the first metatarsal bone. All patients presented with unilateral congenital hallux varus deformity and underwent surgical treatment. The radiographs and medical records were reviewed to evaluate the deformity characteristics, treatment, and clinical results. The mean patient age at initial surgery was 34 (range 12 to 63) months, and the median follow-up period was 46 (range 31 to 75) months. Almost all specific radiographic measurements showed correction of the deformity, and each foot demonstrated functional and cosmetic improvement. A standardized literature search was performed to obtain studies of LEB of the first metatarsal bone in the pediatric population. From on our results and the current data available, surgical treatment should be tailored to the patient's age and radiographic stage of LEB. However, monitoring until skeletal maturity of the feet is necessary to assess the final results.

Intramedullary Metatarsal Fixation for Treatment of Delayed Regenerate Bone in Lengthening of Brachymetatarsia.

Delayed regenerate healing after distraction osteogenesis can be a challenging problem for patients and surgeons alike. In the present study, we retrospectively reviewed the data from a cohort of patients with delayed regenerate healing during gradual lengthening treatment of brachymetatarsia. Additionally, we present a novel technique developed by 1 of us (B.M.L.) for the management of delayed regenerate healing. We hypothesized that application of intramedullary metatarsal fixation would safely and effectively promote healing of poor quality, atrophic regenerate during bone lengthening in brachymetatarsia correction. We formulated a study to retrospectively review the data from a cohort of patients with delayed regenerate healing after gradual lengthening for brachymetatarsia. All patients underwent temporary placement of intramedullary fixation after identification of delayed regenerate healing. Patient-related variables and objective measurements were assessed. We identified 10 patients with 13 metatarsals treated with intramedullary fixation for delayed regenerate healing. All 10 patients were female, with 6 (46.2%) right metatarsals and 7 (53.8%) left metatarsals treated. No complications developed with the use of this technique. All subjects progressed to successful consolidation of the regenerate bone at a mean of 44.5 ± 30.2 days after placement of intramedullary metatarsal fixation. No regenerate fracture or reoperations were noted. In conclusion, intramedullary metatarsal fixation is a safe and effective method for managing delayed regenerate healing encountered during distraction osteogenesis correction of brachymetatarsia.

Return to sporting activity after osteochondral autograft transplantation for Freiberg disease in young athletes.

INTRODUCTION: Freiberg disease is defined as osteochondrosis of the metatarsal head and typically occurs in adolescents with sporting activity. This study aimed to evaluate the sporting activity of young athletes after osteochondral autograft transplantation (OAT) for Freiberg disease. MATERIALS AND METHODS: OAT for Freiberg disease was conducted in 12 consecutive patients between August 2008 and November 2014. The present study evaluated 10 of these patients who both undertook sporting activity preoperatively and were teenagers at the time of surgery. Clinical evaluations were performed based on the Japanese Society for Surgery of the Foot lesser metatarsophalangeal-interphalangeal scale (JSSF scale) and range of motion (ROM) of the operated metatarsophalangeal joint preoperatively and at the final follow-up (mean 24.6 months). Whether patients were able to return to sporting activity and time until return to sporting activity were evaluated, including the Halasi score to reflect the level of sporting activity. Regarding symptoms at the donor knee, the Lysholm knee scale score was evaluated at the final follow-up. RESULTS: The mean JSSF scale showed a significant improvement at the final follow-up (p < 0.01). The mean ROM in extension and flexion improved at the final follow-up (p < 0.01, and p < 0.05, respectively). All patients were able to return to sporting activity at a mean time of 3.5 months postoperatively and the Halasi score showed no significant change. The mean Lysholm knee scale score was 97.9 (range 89-100) points at the final follow-up. CONCLUSIONS: All young athletes who underwent OAT for Freiberg disease achieved early return to almost equal sporting activity postoperatively and exhibited a significant improvement of the ROM of the metatarsophalangeal joint with almost no knee pain.

Anatomical reconstruction of the fourth brachymetatarsia with one-stage iliac bone and cartilage cap grafting.

BACKGROUND: We present a one-stage procedure for lengthening the fourth brachymetatarsia with autogenous iliac bone and cartilage cap grafting for the anatomical reconstruction of the metatarsophalangeal (MTP) joint METHODS: During the last 8 years, 56 feet in 41 patients with congenital brachymetatarsia of the fourth toe were corrected with a one-stage operation to reposition the articular cartilage cap to the distal part of interpositional iliac bone graft at the metatarsal epiphysis. RESULTS: The length of the harvested iliac bone graft was 22.9 mm on average. The mean fixation period was 58.5 days, and the mean gain in length and percentage increase was 20.9 mm and 39%, respectively. MRI showed a stable MTP joint over viable cartilage cap in 83.3% of the cases. Mean postoperative American Orthopedic Foot and Ankle Society lesser MTP-interphalangeal score was 82.0. Neither neurovascular impairment nor recurrence of brachymetatarsia occurred in the mean follow-up period of 43.6 months. All patients were satisfied with the postoperative cosmetic results. Thirteen patients (23.2%) complained of limited active dorsiflexion of the fourth toe, and extensor adhesion was released by extensor tenolysis in only one patient. In a single case of nonunion at the bone graft site, additional surgery was not necessary. CONCLUSIONS: Anatomical reconstruction of the fourth brachymetatarsia with one-stage interpositional iliac bone and cartilage cap grafting resulted in excellent cosmetic results and a physiologic MTP joint, providing the benefits of one-stage lengthening with a low complication rate. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.