Avascular Necrosis of the First Metatarsal: A Case of Second Metatarsal Bone Transport with External Fixation.

Avascular necrosis (AVN) after bunion surgery is an unfortunate complication which can be devastating and painful. We present a case report of gradual medializing transport of the second metatarsal with external fixation to repair a large bone defect caused by AVN affecting >50% of the first metatarsal. The procedure was performed on a 49-year-old female who suffered AVN after failed bunion surgery. At 12-month follow up, first ray position and length were maintained. With respect to the second ray, there were no clinically significant issues. The second digit was mildly elevated but there was no frank instability of the toe or of the Lisfranc complex. The patient was pain free and had returned to her desired daily activities.

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.

Risk Factors Associated With Nonunion After Elective Foot and Ankle Reconstruction: A Case-Control Study.

Postoperative nonunion is not uncommon in the lower extremity, and significant morbidity can be associated with nonunion of the foot and ankle after surgical reconstruction. For the purposes of the present study, we retrospectively reviewed and compared a cohort of patients who had undergone elective foot and ankle reconstruction to better assess the modifiable risk factors associated with postoperative nonunion. We hypothesized that the presence of endocrine and metabolic abnormalities are often associated with nonunion after foot and ankle surgical reconstruction. We formulated a matched case-control study that included 29 patients with nonunion and a control group of 29 patients with successful fusion to assess the prevalence of certain modifiable risk factors known to have an association with nonunion after foot and ankle arthrodesis. The modifiable risk factors assessed included body mass index, tobacco use, diabetes mellitus, vitamin D abnormality, thyroid dysfunction, and parathyroid disease. A statistically significant (p < .05) difference was found between the 2 groups for endocrine and metabolic disease diagnoses in the medical records of the 58 patients identified. Thus, 76% versus 26% (p < .05) of patients experienced nonunion in the endocrine disease group versus the nonendocrine disease group, respectively. Patients with vitamin D deficiency or insufficiency were 8.1 times more likely to experience nonunion (95% confidence interval 1.996 to 32.787). No statistically significant differences were found between the groups in terms of age, sex, tobacco use, body mass index, or procedure selection (p = .56, p = .43, p = .81, p = .28, and p = 1.0, respectively). A greater prevalence of endocrine abnormalities, in particular, vitamin D deficiency and insufficiency, was associated with nonunion after elective foot and ankle reconstruction. Patients with such abnormalities appear to have a greater risk of developing nonunion after arthrodesis procedures.

Procedure selection for the flexible adult acquired flatfoot deformity.

Adult acquired flatfoot represents a spectrum of deformities affecting the foot and the ankle. The flexible, or nonfixed, deformity must be treated appropriately to decrease the morbidity that accompanies the fixed flatfoot deformity or when deformity occurs in the ankle joint. A comprehensive approach must be taken, including addressing equinus deformity, hindfoot valgus, forefoot supinatus, and medial column instability. A combination of osteotomies, limited arthrodesis, and medial column stabilization procedures are required to completely address the deformity.