Positron emission tomography assessment of metacarpal/metatarsal condylar fractures post surgical repair: Prospective study in 14 racehorses.

OBJECTIVES: To assess 18F-sodium fluoride (18F-NaF) positron emission tomography (PET) findings associated with metacarpal/metatarsal condylar fractures at the time of fracture repair and through healing. STUDY DESIGN: Prospective descriptive study. ANIMALS: Fourteen Thoroughbred racehorses. METHODS: 18F-NaF PET was performed within 4 days of surgical metacarpal/metatarsal condylar fracture repair, on both the injured and contralateral limb. Follow-up PET scans were offered at 3- and 5-months post fracture repair. Areas of abnormal uptake were assessed using a previously validated grading system. RESULTS: Eight fractures were located in the parasagittal groove (PSG) (six lateral and two medial) and six fractures were located abaxial to the PSG (non-PSG) through the palmar/plantar condyle (all lateral). All horses in the latter group had uptake in the lateral palmar condyle of the contralateral limb suggestive of stress remodeling. Three horses with PSG fractures had uptake in a similar location in the contralateral limb. Horses with lateral condylar fracture only presented minimal or mild uptake in the medial condyle, which is considered atypical in the front limbs for horses in full training. Four horses developed periarticular uptake in the postoperative period suggestive of degenerative joint disease, three of these horses had persistent uptake at the fracture site. These four horses did not return to racing successfully. CONCLUSION: The findings of this study provide evidence of pre-existing lesions and specific uptake patterns in racehorses suffering from metacarpal/metatarsal condylar fractures. CLINICAL SIGNIFICANCE: PET has a possible role in the prevention, diagnosis, and postoperative monitoring of metacarpal/metatarsal condylar fractures in racehorses.

Radiographic Assessment of Relationship Between Medial Cuneiform Obliquity and Hallux Valgus.

The research results are inconsistent that assessing whether the increased obliquity of the distal articular surface of the medial cuneiform leads to an increase in hallux valgus angle. Thus, this study investigated the relationship between distal medial cuneiform obliquity and hallux valgus by measuring various angles in weightbearing anteroposterior radiographs of the foot. In total, 679 feet of 538 patients with the radiographs were included in the study. We measured radiographic parameters including hallux valgus angle, first to second intermetatarsal angle, metatarsus adductus angle, first metatarsus cuneiform angle, distal medial cuneiform angle, and first proximal metatarsal articular angle. The surface morphology (flat or curved) of the first tarsometatarsal joint was also recorded. Our results analysis revealed a weak negative correlation between distal medial cuneiform angle and both hallux valgus angle and first to second intermetatarsal angle, contrary to our assumption. So we believe that distal medial cuneiform angle was relatively constant and it cannot be used as a characteristic angle for quantifying hallux valgus. First metatarsus cuneiform angle was a characteristic indicator of hallux valgus and was positively correlated with its severity (p < .000), indicating that it can be used to measure the size of hallux valgus. It can also be used as a reference factor for the first metatarsal osteotomy in clinical bunion orthopedics. First tarsometatarsal joint morphology was unrelated to hallux valgus, whereas metatarsus adductus angle, and first proximal metatarsal articular angle should be considered in hallux valgus.

Intra­ and Interobserver Reliability of Yamaguchi's Method for the Assessment of First Metatarsal Pronation in Hallux Valgus Deformity.

Pronation of the first metatarsal is a risk factor for the formation and progression of the hallux valgus deformity. Recently, Yamaguchi et al published a study that showed how the round sign increases on digitally reconstructed radiography taken from a CT scan when pronation is applied. In this study, the shape of the lateral edge of the first metatarsal head was evaluated on weightbearing dorsoplantar radiographs. Yamaguchi's signs were presented to observers after the visual presentation of each foot as an image. The best-fit circle was drawn using the PACS drawing function. Ninety radiographs of adults presenting hallux valgus deformities were classified as mild-to-moderate, based on hallux valgus angle and intermetatarsal angle. The global average observations were 3.72 ± 3.92 (range 2.3°-4.6°). The interclass correlation (Fleiss Kappa index κ = 0.225) and the Spearman correlation (0.16 of Kappa) coefficients were poor for interobserver measurements and statistically significant. Using the linear model, there was no significant variability between the repetitions corresponding to each observer (t-value -1.527, p value .127). Our findings show that the Yamaguchi method can be very subjective and should not be the exclusive technique to assess the rotation of the first metatarsal or head roundness.

Screw versus staple fixation for Akin osteotomy.

INTRODUCTION: Akin osteotomies are commonly fixed with a screw or staple. Hardware-related symptoms are not uncommon. We compared the outcomes and costs of the two implants. METHODS: We evaluated 74 Akin osteotomies performed in conjunction with first metatarsal osteotomy for hallux valgus. The osteotomy was fixed with a headless compression screw in 39 cases and a staple in 35 cases. We looked at the implant-related complications, removal of metalwork, revision, non-union and cost. Pre- and postoperative hallux valgus interphalangeal (HI) angles and length of the proximal phalanx were measured. RESULTS: There was 100% union, no failure of fixation, no revision surgery and no delayed union in either group. The radiological prominence of screws was significant (p=0.02), but there was no significant difference in soft-tissue irritation (p=0.36) or removal of implants (p=0.49). Two cortical breaches (5.8%) occurred in staple fixation and 4 (10.2%) in screw fixation (not statistically significant (NS), p=0.50). The mean improvement in HI angle was 4.3° with screw fixation and 4.1° with staple fixation (NS, p=0.69). The mean shortening of the proximal phalanx was 2.5mm with screw fixation and 2.3mm with staple fixation (NS, p=0.64). The total cost was £1,925 for staple fixation and £4,290 for screw fixation. CONCLUSIONS: Staple and screw fixation are reproducible modalities with satisfactory outcomes, but screw fixation is expensive. We conclude staple fixation is a cost-effective alternative.

Distal Metatarsal Minimally Invasive Osteotomy (DMMO): Surgical technique, variants, indications, and treatment decision-tree.

BACKGROUND: Metatarsal osteotomy is a major means of treating mechanical metatarsalgia. Open techniques are widely used, and notably that described by Weil. They have, however, certain drawbacks, and new types of osteotomy have been developed. Percutaneous techniques are presently very much in favor, and Distal Metatarsal Minimally Invasive Osteotomy (DMMO) has emerged as a treatment for metatarsalgia. Although very widely used, it is poorly codified in the literature. METHOD: The present study detailed DMMO techniques and their variants (oblique and reverse), with corresponding indications and treatment decision-tree. RESULTS: Initial findings seem encouraging, with functional results comparable to those of open surgery. Postoperative edema and radiologic bone healing time seem to be longer in DMMO. There is, on the other hand, no difference regarding stiffness. CONCLUSION: DMMO is an effective option to treat metatarsalgia, with variants enabling adaptation to foot morphology, but needing confirmation by studies with higher levels of evidence.

Radiographic Assessment of Relative First Metatarsal Length Following Modified Lapidus Procedure.

BACKGROUND: The modified Lapidus is a surgical procedure for managing moderate to severe hallux valgus, especially in the presence of first tarsometatarsal joint arthritis or hypermobility. It has good long-term results but reportedly can lead to transfer metatarsalgia due to inherent shortening of the first metatarsal. METHODS: A retrospective analysis of all adult patients who underwent a modified Lapidus procedure during a 3-year period was performed. Clinical notes were evaluated to look for nonunion or any other complications related to the surgery. Pre- and postoperative standard weightbearing radiographs were used to establish the relative metatarsal length (RML), intermetatarsal angle (IMA), hallux valgus angle (HVA), and distal metatarsal articular angle (DMMA). A total of 69 modified Lapidus procedures were identified, with 32 included in the study. RESULTS: The mean pre- and postoperative RMLs were -0.8 and -4.9 mm, respectively. The average RML shortening due to the procedure was -4.1 (P < .0001). The mean pre- and postoperative IMAs were 15 and 5 degrees, respectively (P < .0001). The mean pre- and postoperative HVAs were 33 and 9 degrees, respectively (P < .0001). One patient reported transfer metatarsalgia, which was attributed to elevation of the first metatarsal. CONCLUSION: We found a statistically significant degree of shortening of the relative length of the first metatarsal without any clinically significant metatarsalgia. The low rate of transfer metatarsalgia following the modified Lapidus procedure could be attributed to the sagittal plane correction and stability obtained by performing a first tarsometatarsal fusion. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Biomechanical and Histological Assessment of a Polyethylene Terephthalate Screw Retention Technology in an Ovine Metatarsal Fracture Model.

OBJECTIVE: Screw loosening in fracture fixation poses a clinical risk which may lead to implant failure, particularly in poor bone quality. The objective of this study was to examine the effectiveness of a novel screw retention technology (SRT) for increased screw purchase in a large animal metatarsal fracture model. STUDY DESIGN: This was a biomechanical, radiographic, and histological study utilizing an ovine metatarsal fracture model. Twenty-four sheep metatarsi underwent 3-mm ostectomies and were repaired with a nine-hole plate and 3.5-mm screws placed in oversized 3.5-mm holes to simulate worst case revision surgeries (i.e. no initial screw thread bone contact). Sheep were sacrificed at 3, 6 or 12 weeks (n = 6 each) post-operation. Post-sacrifice, each surgically implanted screw underwent either destructive mechanical testing or histomorphometric analyses. RESULTS: Treated metatarsi showed improved screw retention and normal fracture healing. Significant improvement in breakout strength and pullout strength of screws treated with the SRT were found as a function of healing time. Histologically, bone ingrowth at the screw interface was also shown to significantly increase with healing time. Improvements in fracture healing, indicated by an increase in bone fraction and decrease in void space at the osteotomy, were also observed with healing time. CONCLUSION: The results demonstrate the effectiveness of the SRT as a method for improved screw retention in a rescue-screw type scenario.

Assessment of Outcomes of a Metatarsal Bone Ostectomy for Chronic Plantar Ulcers: A Preliminary Study.

BACKGROUND: Clinical management of chronic plantar ulcers is a difficult issue in medical practice. Pressure overloading is a problem that needs to be resolved. Herein, we report a surgical method to reduce plantar pressure: a dorsal approach to a metatarsal ostectomy. METHODS: From March 2011 to October 2016, 16 patients suffering from chronic plantar ulcers underwent ostectomy procedures at Taipei Wan-Fang Municipal Hospital (Taipei Medical University). A bone segment about 0.5 to 1 cm long was removed via a dorsal foot approach. The plantar wound was treated with debridement only or was simultaneously covered with a skin graft. In total, 16 patients with an average age of 57.81 (SD, 11.6) years (12 males and 4 females) were included; 15 patients (93.75%) had a diagnosis of type 2 diabetes for a mean of 20.66 years (range, 5-30 years). The mean glycated hemoglobin was 9.14 g/dL (range, 5.2-13.2 g/dL). The mean plantar wound size was 5.72 cm. Four patients (25%) needed to receive a skin graft with a mean skin graft size of 8.13 cm. RESULTS: The mean follow-up time was 15.2 months. The plantar wounds completely healed in 14 patients (87.5%) in an average of 2.14 months. No plantar ulcer was complicated with recurrence, but transfer ulcers developed in 2 patients (12.5%) at an average of 7.5 months postoperatively. CONCLUSIONS: Metatarsal ostectomy surgery via a dorsal foot approach is an efficient way to reduce pressure overloading of chronic plantar wounds. Our study provides an alternative method to treat this difficult problem with a high wound healing rate and less recurrence.

Effect of metatarsal osteotomy and open lateral soft tissue procedure on sesamoid position: radiological assessment.

BACKGROUND: Incomplete sesamoid reduction is a potential risk factor for the recurrence of hallux valgus. The purpose of this study was to radiologically investigate changes in sesamoid position after chevron osteotomy and the open lateral soft tissue procedure. METHODS: Sixty-eight feet that underwent operative correction for hallux valgus deformity were reviewed consecutively. The hallux valgus angle (HVA), first to second intermetatarsal angle (IMA), tibial sesamoid position (TSP), distance of the fibular sesamoid (DFS), and translation of the metatarsal head (TMH) were evaluated preoperatively and at final follow-up. RESULTS: While most parameters were significantly decreased after surgery, no significant change in DFS (correction - 1.45 mm, p = 0.08) was noted. The difference between preoperative and postoperative TSP values (ΔTSP) has a moderately positive correlation with difference in TMH values (ΔTMH) (Rho 0.475, p = .000). Other parameters were similarly correlated. CONCLUSIONS: First, metatarsal bone realignment reduced the sesamoid, but its position, relative to the second metatarsal axis (DFS), was unchanged. The sesamoid is reduced by the lateral translation of the first metatarsal but not by medial sesamoid migration.

Suture fixation of an Akin osteotomy: A cost effective and clinically reliable technique.

BACKGROUND: The Akin osteotomy is commonly performed as an adjunct to osteotomies of the first metatarsal for the correction of hallux valgus such as the scarf or chevron osteotomies. The Akin osteotomy is indicated for the correction of a hallux valgus interphalangeus and can be used supplementary in any first metatarsal osteotomy for a hallux valgus. Various techniques have been described for fixation of the osteotomy. Most commonly the osteotomy is held and fixed with metalwork consisting of either a staple [2,3], a screw [4,5] or wiring [6,7]. While these techniques have been shown to be effective they are not without complications. They may require the use of additional instrumentation and in particular there is a described incidence of subsequent implant removal due to irritation of surrounding tissues and migration of the implanted metalwork [8-12]. Suture fixation of osteotomies in the foot has previously been described [14,15]. This offers a cost effective method with reliable results without the risk of implant complication. METHOD: In this study we report the outcomes of a large series performed by a single surgeon and compare them to a similar series of Akin osteotomies performed by a different surgeon at the same institute using the staple technique. RESULTS: The results demonstrate no significant difference in outcome between the two series and a significant cost saving with the use of the suture fixation. CONCLUSIONS: As a result of the study, we advocate the use of suture fixation of Akin osteotomy as a cost effective and reliable alternative to other forms of fixation.

The Mechanical Axis of the First Ray: A Radiographic Assessment in Hallux Abducto Valgus Evaluation.

The present report describes a new method of hallux abducto valgus deformity correction planning using the mechanical axis of the medial column (mechanical axis planning). This method of radiographic evaluation identifies an ideal position for the first metatarsal after correction and is useful regardless of the surgical procedure chosen. We retrospectively reviewed 200 radiographs to identify a "normal" value for the mechanical axis angle. We reviewed 100 radiographs of patients with hallux abducto valgus deformity (deformity group) and 100 radiographs of patients without hallux abducto valgus deformity (control group). The deformity group revealed an M1-M2 anatomic axis angle of 13.5° ± 2.83° and an M1-M2 mechanical axis angle of 11.58° ± 1°. The control group revealed an M1-M2 anatomic axis angle of 7.5° ± 1.76° and an M1-M2 mechanical axis angle of 11.19° ± 0.9°. The differences in the M1-M2 anatomic axis angle and M1-M2 mechanical axis angle were statistically significant between the control and deformity groups. We sought to provide a reliable method for planning hallux abducto valgus deformity correction by aligning the mechanical axis of the medial column and the mechanical axis of the first ray to the "normal" value of 11° to reduce the deformity.

Radiographic Relevance of the Distal Medial Cuneiform Angle in Hallux Valgus Assessment.

The angle formed by the distal articular facet of the medial cuneiform has been evaluated and discussed by various investigators. However, no consistent method has been available to radiograph and measure this entity. The wide variability of the angle is not conducive to comparative analysis. Additionally, investigators have noted that the angles observed (obliquity) vary greatly because of changes in radiographic angle, foot position, rotation of the first ray, and declination of the first metatarsal. Recognizing that these variables exist, we propose a reproducible assessment using digital radiography and application of deformity of correction principles. Our results have indicated a mean distal medial cuneiform angle of 20.69° in normal feet, 23.51° with moderate hallux valgus, and 20.41° with severe hallux valgus deformity. The radiograph beam was kept at 15° from the coronal plane. An inverse relationship was found between the distal medial cuneiform angle and bunion severity. This was in contrast to our expected hypothesis. The overall angle of the first metatarsal-medial cuneiform did, however, correlate with the severity of the bunion deformity (p < .000). The obliquity values and intermetatarsal angles changed in direct relationship to the radiographic projection angle. This illustrates the importance of using standardized radiographic projection angles. We conclude that the 1-dimensional standard anteroposterior radiograph with assessment of the distal medial cuneiform angle cannot adequately demonstrate the pathologic features of hallux valgus. A better indicator appears to be the first metatarsal-medial cuneiform angle. This pathologic entity is a 3-dimensional one that incorporates the joint morphology of the first ray, triplane osseous positioning, and soft tissue imbalances. Perhaps, 3-dimensional computed tomography imaging will provide better insight into this entity.

The effect of concentrated bone marrow aspirate in operative treatment of fifth metatarsal stress fractures; a double-blind randomized controlled trial.

BACKGROUND: Fifth metatarsal (MT-V) stress fractures often exhibit delayed union and are high-risk fractures for non-union. Surgical treatment, currently considered as the gold standard, does not give optimal results, with a mean time to fracture union of 12-18 weeks. In recent studies, the use of bone marrow cells has been introduced to accelerate healing of fractures with union problems. The aim of this randomized trial is to determine if operative treatment of MT-V stress fractures with use of concentrated blood and bone marrow aspirate (cB + cBMA) is more effective than surgery alone. We hypothesize that using cB + cBMA in the operative treatment of MT-V stress fractures will lead to an earlier fracture union. METHODS/DESIGN: A prospective, double-blind, randomized controlled trial (RCT) will be conducted in an academic medical center in the Netherlands. Ethics approval is received. 50 patients will be randomized to either operative treatment with cB + cBMA, harvested from the iliac crest, or operative treatment without cB + cBMA but with a sham-treatment of the iliac crest. The fracture fixation is the same in both groups, as is the post-operative care.. Follow up will be one year. The primary outcome measure is time to union in weeks on X-ray. Secondary outcome measures are time to resumption of work and sports, functional outcomes (SF-36, FAOS, FAAM), complication rate, composition of osteoprogenitors in cB + cBMA and cost-effectiveness. Furthermore, a bone biopsy is taken from every stress fracture and analysed histologically to determine the stage of the stress fracture. The difference in primary endpoint between the two groups is analysed using student's t-test or equivalent. DISCUSSION: This trial will likely provide level-I evidence on the effectiveness of cB + cBMA in the operative treatment of MT-V stress fractures. TRIAL REGISTRATION: Netherlands Trial Register (reg.nr NTR4377 ).

Comparison of postoperative costs of two surgical techniques for hallux valgus (Kramer vs. scarf).

BACKGROUND: Most studies of hallux valgus surgery focus on the radiological findings or on medium-term clinical follow-up. The results obtained using various osteotomy techniques do not differ greatly. However, patient comfort and the need for postoperative care do appear to present differences. In the Kramer technique, the osteotomy is secured with a wire extruding from the skin of the foot. In this situation, patients may well experience problems (or at least discomfort) in the immediate postoperative period. Previous studies of the Kramer technique (also known as SERI, or percutaneous distal metatarsal osteotomy) do not report an increased number of complications. Early complications may not influence the outcome in the medium to long term, and patient discomfort during the postoperative period is rarely reflected in the analysis of one-year results obtained with standard scales such as AOFAS; in our experience, however, patient discomfort, the care burden (i.e., the number of visits and emergency service consultations) and the economic cost of immediate postoperative care are all aspects that should be borne in mind when assessing the merits of different surgical techniques. In this study we compare the care burden and economic cost of two surgical approaches to hallux valgus correction--the Kramer and the scarf techniques--during the first postoperative year. METHODS: Retrospective review of two independent patient cohorts. Sixty-nine feet underwent Kramer osteotomy and 133 the scarf technique. Care burden was assessed by the number of visits each patient required and the complications. The follow-up and costs of each were assessed and compared independently. RESULTS: Both techniques obtain satisfactory clinical results at one year. However, comparison of clinical progression showed AOFAS score increases of 34.7 points for Kramer and 41.1 points for the scarf technique (p-value<0.05). Patients in the Kramer group required a higher number of visits, especially postoperative emergency department visits (p<0.05), and had a significantly higher number of complications (27.5% vs. 6.7%, p<0.05). The mean cost of follow-up was significantly higher in the Kramer group (€ 218.97 vs. € 171.41, p<0.05). CONCLUSIONS: Kramer osteotomy presented significantly higher care burdens, complication rates and associated costs during the first year of follow-up. It is therefore a less cost-effective technique. Thus, even though according to the results of AOFAS we would not have changed our clinical practice, the analysis of these data has made us change our treatment strategy for hallux valgus and practically abandoned the use of the Kramer osteotomies.

Assessment of partial first-ray resections and their tendency to progress to transmetatarsal amputations: a retrospective study.

BACKGROUND: Diabetic foot infections tend to lead to amputation. Partial first-ray resections are used to help salvage the foot and maintain bipedal ambulation. Losing the first metatarsophalangeal joint has biomechanical consequences that lead to further foot deformities and result in more proximal amputations of the ipsilateral limb, such as a transmetatarsal amputation. METHODS: We reviewed 48 patients (32 male and 16 female; mean age = 62.44) who underwent 50 partial first-ray resections between April 1, 2003, and July 31, 2009. These partial first-ray resections were done at various levels of the first metatarsal. We hypothesize that partial first-ray resections that require further bone resection will lead to poor biomechanics that can result in further amputation. RESULTS: We found that out of 50 partial first-ray resections, 24 cases required further surgical intervention, 12 of which were a transmetatarsal amputation (TMA) (mean time between partial first-ray resection and TMA = 282.08 days). Forty-eight percent of patients did not require further surgical intervention and were considered a success. CONCLUSIONS: Partial first-ray resections are not highly successful. Our study found a higher success rate compared to a previous study done by Cohen et al in 1991. Partial first-ray amputations can be a good initial procedure to salvage the foot and prolong a patient's bipedal ambulatory status, thereby lowering the patient's morbidity and mortality.

Metatarsal extension osteotomy without plantar aponeurosis release in cavus feet. The effect on claw toe deformity a radiographic assessment.

BACKGROUND: This study reviewed patients undergoing correction of cavus foot deformity by metatarsal extension osteotomy with preservation of the plantar aponeurosis, and assessed the correction achieved of the claw deformity of the toe by radiographic assessment. METHOD: 15 patients (18 feet) were reviewed clinically and radiographically. All feet required extension osteotomy of the first metatarsal and four patients (5 feet) had extension osteotomy of the first to fourth metatarsals. Hallux extension angle in relation to the 1st metatarsal and in relation to the ground was measured in all feet to estimate the degree of clawing of the hallux. RESULTS: 13 patients (15 feet) were satisfied with the outcome of their surgery and also the appearance of their foot. The mean radiographic change in the hallux extension angle in relation to the 1st metatarsal was 16°, and in relation to the ground was 7°. These changes were statistically significant. CONCLUSION: Our results indicate an improvement in the claw toe deformity and we recommend preservation of the plantar aponeurosis in corrective surgery for cavus foot.

Fractures of the proximal fifth metatarsal: keeping up with the Joneses.

Fractures of the proximal fifth metatarsal are among the most common fractures of the foot. History, physical examination, and subsequent radiographic work-up can help with the diagnosis of such a fracture. Many fractures of the proximal fifth metatarsal can have an associated prodrome, thereby establishing a level of chronicity to the problem. Identification of the location of the fracture plane within the proximal fifth metatarsal can have prognostic implications in regards to fracture union rate and guide treatment options, due to the particular vascular anatomy of the region. Additional findings on physical exam, such as heel varus, can also impact prognosis and treatment options. Treatments can range from nonoperative to operative modalities, and time to weightbearing can vary. Within the realm of operative treatment, identification of certain parameters can aid in successful reduction and fixation of the fracture and thus impact healing. Careful consideration of the patient's particular constellation of social and professional needs, clinical and radiographic parameters, and acceptance of different options can help guide treatment recommendations in the individual patient.

Freiberg's disease: quantitative assessment of osteonecrosis on three-dimensional CT.

BACKGROUND: The extent of necrosis is the main determining factor in the outcome of osteonecrosis. There is no method for measuring the extent of osteonecrosis of the metatarsal head in Freiberg's disease. The purpose of this study was to determine the reliability and prognostic ability of a new method for measurement of the extent of osteonecrosis in Freiberg's disease on three-dimensional computed tomography. METHODS: A retrospective review of 11 cases with symptomatic Freiberg's disease in ten patients (5 males and 5 females; mean age, 27 years) undergoing computed tomography between July 2005 and September 2007 was performed. Two investigators (K.A.C. and H.K.O.) used a new method to measure the necrotic extent of the metatarsal head: the necrotic angle ratio of necrotic arc angle to normal arc angle of the articular surface on the sagittal reconstruction image of computed tomography. The interobserver reliability was determined for computed tomography measurement. Correlation between the Smillie staging using radiographs and the necrotic angle ratio on computed tomography was also evaluated. RESULTS: One patient presented with stage I disease (Smillie staging), one with stage II, two with stage III, five with stage IV, and two with stage V, respectively. The necrotic angle ratio of the metatarsal head was 14% in stage I, 21% in stage II, 34% in stage III, 43% in stage IV, and 53% in stage V. The interobserver reliability for computed tomography measurement was high (Cronbach α=0.96). We found the increase of the necrotic extent in proportion to the Smillie stage. The Smillie staging using radiographs and the necrotic angle ratio on computed tomography were significantly correlated. (P<0.05) CONCLUSIONS: Three-dimensional computed tomography measurement of the necrotic extent of the metatarsal head is a reliable and useful method in evaluating the staging of Freiberg's disease and may eventually help to optimize treatment.

Preoperative Doppler assessment for transmetatarsal amputation.

A thorough preoperative vascular evaluation should be performed before the initiation of any lower extremity surgical intervention, but particularly in situations of diabetic foot reconstruction with compromised blood flow. The intended emphasis of this brief report is to provide the foot and ankle surgeon with an appreciation for the clinical vascular anatomy of the transmetatarsal amputation through a handheld Doppler examination.

[The efficacy assessment of cuboid and medial cuneiform bone wedge ostetomy in the treatment of metatarsus adductus]. / Ocena skutecznosci osteotomii klinowej kosci szesciennej i klinowatej przysrodkowej w leczeniu przywiedzenia przodostopia.

Metatarsus adductus is usually a morphologic feature of the clubfoot or occurs as an isolated defect. Such deformation causes shortening of the medial foot column and lengthening of the lateral. The purpose of the study is a retrospective evaluation of long-term therapeutic effects in a group of patients, who underwent closing wedge cuboid osteotomy and opening wedge medial cuneiform osteotomy. Surgery was performed in 19 persons, procedure was applied to 26 feet, of which 3 presented congenital metatarsus adductus and 23 presented recurrent clubfoot. During ostoetomy we performed additional corrective procedures on soft tissues. Foot and gait deformation, pain associated with activities, presence of calluses on the lateral plantar surface of the foot, difficulty in footwear were evaluated before and after surgery on clinical examination. The pre- and post operative X-rays were used to determine: in AP view the Kite's angle and the angle between the calcaneal bone and the 5th metatarsalbone (forefoot adduction evaluation), in lateral view the Kite's angle, the angle between the calcaneal bone and the 1st metatarsal bone (forefoot supination evaluation) and the angle between the talus and the 1st metatarsal bone (cavus evaluation). An early recurrence of the deformation after the removal of wire fixation occurred in 2 patients. Late complications taking the form of adduction and supination of the forefoot occurred in 5 cases. In general recurrences of adduction of the metatarsus occurred in 27 % operated feet. Radiographic evaluation proved a significant statistical effect of the "plus-minus" osteotomy limited to the reduction of the adduction angle of the forefoot and not affect improvement of the supination of the forefoot and the foot excavation.