Treatment of Freiberg's disease using a reverse pedicled metatarsal bone flap: Case report.

Despite no surgical procedures receiving unanimous support for treating Freiberg's disease, several surgical treatment options have been described. For the past few years, bone flaps have been shown in children to present promising regenerative properties. We report a novel technique using a reverse pedicled metatarsal bone flap from the first metatarsal to treat one case of Freiberg's disease in a 13-year-old female. The patient presented 100% involvement of the second metatarsal head, with a 6 × 2 mm defect, unresponsive to 16 months of conservative measures. A 7 mm × 3 mm pedicled metatarsal bone flap (PMBF) was obtained from the lateral proximal first metatarsal metaphysis, mobilized and pedicled distally. It was inserted at the dorsum of the distal metaphysis of the second metacarpal towards the center of the metatarsal head, reaching the subchondral bone. Initial favorable clinical and radiological results were maintained for over 36 months during the last follow-up. Based on the powerful vasculogenic and osteogenic properties of bone flaps, this novel technique could effectively induce bone revascularization and prevent further collapse of the metatarsal's head.

Metatarsal head restoration versus dorsal closing-wedge osteotomy in the treatment of advanced-stage Freiberg's disease.

PURPOSE: Freiberg's disease is mostly characterized by osteonecrosis of second metatarsal head and is widely seen in adolescent women. Metatarsal head restoration technique is a novel surgical procedure intended to protect intact articular surface and regenerate avascular bone under cartilage. This study aimed to evaluate and compare the results and clinical outcomes of metatarsal head restoration technique with those of dorsal closing-wedge osteotomy technique in patients with advanced-stage Freiberg's disease. METHODS: In this retrospective study, 60 patients who were operated for Freiberg's disease were evaluated. Patients were divided into two groups as who underwent metatarsal head restoration and dorsal closing-wedge osteotomy. Groups were compared according to "American Orthopaedic Foot & Ankle Society score" (AOFAS), "visual analog score" (VAS) and passive "range of motion" (ROM) score. RESULTS: Thirty-two feet of 29 patients underwent metatarsal head restoration, while 33 feet of 31 patients were subject to dorsal closing-wedge osteotomy. Mean AOFAS score increased from 58.72 ± 6.89 to 89.35 ± 7.43 following metatarsal head restoration, while it increased from 54.13 ± 6.12 to 78.24 ± 6.54 after dorsal closing-wedge osteotomy. Mean VAS score decreased from 6.89 ± 1.18 to 1.33 ± 0.64 after metatarsal head restoration, while it decreased from 6.64 ± 0.92 to 2.71 ± 1.91 following dorsal closing-wedge osteotomy. Mean ROM increased from 12.25° ± 1.65 to 56.28° ± 2.77 after metatarsal head restoration, and it increased from 11.18° ± 0.66 to 47.65° ± 2.05 after dorsal closing-wedge osteotomy (all p < 0.05). In addition, postoperative mean AOFAS (p = 0.044), VAS (p = 0.041) and passive ROM (p = 0.034) scores improvement were found to be statistically significantly better in the metatarsal head restoration group. CONCLUSION: This study revealed that metatarsal head restoration is a safe and successful surgical technique. It leads to better results than dorsal closing-wedge osteotomy in patients with stages 3-4 Freiberg's disease. LEVEL OF EVIDENCE: III.

Freiberg`s disease of lesser metatarsals treated with bone grafting and autologous matrix induced chondrogenesis (AMIC) membrane - A series of 10 cases.

BACKGROUND: Freiberg's infraction is osteonecrosis of lesser metatarsal heads most commonly affecting adolescent females. They usually present with pain and swelling of the forefoot. MRI is useful investigation in the early diagnosis. It is a self-limiting disease and the main stay of treatment is non operative. Surgery is indicated in failed conservative management which include open debridement, cheilectomy, micro fracture, osteotomies and excision arthroplasty with varying success. METHODS: A retrospective analysis of ten patients with Freiberg`s disease of the lesser metatarsals treated with open debridement, microfracture, bone grafting and application of AMIC (Autologous Matrix induced Chondroplasty) membrane was carried out. The patients were followed up to five years and the outcome measures were scored using Manchester-Oxford Foot Questionnaire (MOxFQ) and EQVAS best health scores. RESULTS: The mean age was 42.7 years and follow-up time was 36.4 months. The most common site was second metatarsal, eight (80%) followed by third metatarsal, two (20%). The mean base line MOxFQ was 72.5 (95% CI- 45 ± 100) which improved to 42.5 (95%CI- 2.5 ± 82.5) at one year. The mean baseline VAS improved from 26.4(10.2 ± 42.6) to 30.3 (95%CI- 2.1 ± 58.5) at one year. The mean MOxFQ and VAS at the end of 36 months was 31.4(95%CI-6.6 ± 57.2) and47.3(4.3 ± 80.3) respectively. CONCLUSIONS: Open debridement of the Freiberg`s disease combined with microfracture of the defect, bone grafting and application of AMIC membrane shows reliable functional and radiological outcomes at short term follow up.

Fibular and metatarsal osteosynthesis in a southern brown howler monkey (Alouatta guariba clamitans).

Here we describe a successful surgical management of a distal fibular fracture combined with a tarsocrural luxation and multiple metatarsal fractures in the left foot of a southern brown howler monkey (Alouatta guariba clamitans). We achieved satisfactory outcome by applying intramedullary pinning for each of the bone fractures and closed reduction of joint luxation-kept in place only by bone alignment, without further ligament reconstruction. Bone healing occurred uneventfully within eight weeks and the monkey's foot regained its normal function. Therefore, we could properly release the patient back into the wild.

Metatarsal Head Restoration With Tendon Autograft in Freiberg's Disease: A Case Report.

Freiberg's disease is a form of osteochondrosis of a metatarsal head that often affects the second metatarsophalangeal joint, and that affects females more often than males. Repetitive microtrauma, osteonecrosis, and stress overload are the main factors in its pathophysiology. Surgical intervention is indicated in advanced cases wherein nonoperative treatment has failed. In this report, we describe the case of a young female who had Freiberg's disease localized to the third metatarsal head bilaterally and who was successfully treated with peroneus longus tendon transplantation.

Outcomes of Polyvinyl Alcohol Hydrogel Implant of the Lesser Metatarsals.

BACKGROUND: Lesser toe metatarsophalangeal (MTP) joint pathology presents a challenge for surgical treatment. At our institution, arthroplasty using a polyvinyl alcohol (PVA) hydrogel implant has been utilized in the second and third MTP joints for advanced arthritis, failed management of Freiberg's infraction, and osteochondral defects. We present a case series describing the clinical outcomes of 13 patients following PVA implantation of the second or third MTP. METHODS: We retrospectively identified 13 patients (14 joints) who underwent PVA hydrogel implantation of the second (n = 12) or third (n = 2) metatarsal between 2017 and 2019. The average age was 49 (range, 20-67) years, with 100% females. Patient-Reported Outcomes Measurement Information System (PROMIS) scores were collected preoperatively and at an average of 21.1 (range, 8.3-29.2) months postoperatively. Clinical outcomes were also evaluated. The average time to clinical follow-up was 24.7 (range, 7-35.8) months. RESULTS: On average, patients demonstrated pre- to postoperative improvement in all PROMIS domains, with significant improvements in Pain Intensity (P = .01) and Pain Interference (P = .01). Five postoperative complications were observed: 1 case of persistent avascular necrosis, 1 revision with implant removal and bone grafting, 1 periprosthetic fracture, and 2 recurrences of pain requiring ultrasound-guided injection. CONCLUSION: This study represents the largest case series to date evaluating the use of PVA implant in the surgical correction of lesser toe MTP joint pathology. While the PVA implant presents a viable option in the setting of advanced arthritis, Freiberg's infraction, and certain osteochondral defects, it is not without complications. The specific indications for use of the PVA implant should be carefully considered. LEVEL OF EVIDENCE: Level IV, case series.

Diagnosis and Operation Results for Chronic Lateral Ankle Instability with Subtle Cavovarus Deformity and a Peek-A-Boo Heel Sign.

Cavovarus deformity is considered an anatomical risk factor for chronic lateral ankle instability (CLAI). However, subtle deformity can be difficult to detect, and its correction is controversial. The current study aimed to evaluate clinical and radiographic outcomes of a modified Broström procedure (MBP) with additional procedures for CLAI with subtle cavovarus deformity and a positive peek-a-boo heel sign. We reviewed the records of 15 patients who underwent MBP with additional procedures for CLAI with a positive peek-a-boo heel sign between August 2009 and April 2015. Consecutive physical and radiographic examinations were performed. The visual analog scale (VAS) for pain, the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, and the Karlsson-Peterson (KP) ankle score were applied to assess clinical outcomes. Weight bearing radiographs, hindfoot alignment view, and ankle stress radiographs were also examined. The mean follow-up period was 58.5 months. Calcaneal lateral closing wedge osteotomy was performed in seven patients to correct fixed hindfoot varus, and first metatarsal dorsiflexion osteotomy was performed in 11 patients to correct plantarflexion of the first ray. Three patients underwent both procedures. Mean VAS, AOFAS, and KP ankle scores improved significantly (p=0.001), and instability did not recur. Radiographically, all stress parameters improved significantly (p=0.007). Simultaneous correction of a positive peek-a-boo heel sign and cavovarus deformity with MBP for CLAI improves clinical outcomes and prevents recurrent instability. A comprehensive evaluation and cautious approach for subtle cavovarus deformity should be followed when treating patients with CLAI. This trial is registered on Clinical Research Information Service (CRiS, KCT0003287).

Application of Chitosan and Chondroitin Sulphate Aerogels in a Patient With Diabetes With an Open Forefoot Transmetatarsal Amputation.

INTRODUCTION: Diabetic foot ulcers may lead to nontraumatic amputations of the foot, leading to a decrease in patient quality of life. Transmetatarsal amputations (TMAs) represent an effective surgical procedure in cases of severe foot infection, but the tissue reconstruction is complicated and additional procedures should be considered. The present case report evaluates the wound closure of an open TMA in a patient with diabetes treated with a new aerogel composed of chitosan (ChS) and chondroitin sulphate (CS), without needing a skin graft. CASE REPORT: A 72-year-old man with diabetes and a history of successive amputations was admitted to a hospital in Valdivia, Chile, due to a severe infection of toes 2 and 4 of the right foot. After the diagnosis of gangrene and osteomyelitis, the patient underwent a TMA of his right forefoot. The surgeon proposed the incorporation of ChS and CS aerogels to accelerate wound healing to avoid another surgical procedure. The TMA surgical wound area closed 50% after day 28 from starting treatment with aerogels. Complete closure was achieved at day 94 of treatment with aerogels, with good epithelial tissue and favorable cosmetic results and without residual limb deformities. The patient experienced minimal physical and psychological impairment from the procedure. Other surgical procedures were not necessary. CONCLUSIONS: Due to the results of this patient, use of ChS and CS aerogels could represent an alternative treatment for forefoot TMA wound closure and prevent further surgical procedures, such as skin grafting. Future works should consider a larger number of cases.

Regeneration of segmental defects in metatarsus of sheep with vascularized and customized 3D-printed calcium phosphate scaffolds.

Although autografts are considered to be the gold standard treatment for reconstruction of large bone defects resulting from trauma or diseases, donor site morbidity and limited availability restrict their use. Successful bone repair also depends on sufficient vascularization and to address this challenge, novel strategies focus on the development of vascularized biomaterial scaffolds. This pilot study aimed to investigate the feasibility of regenerating large bone defects in sheep using 3D-printed customized calcium phosphate scaffolds with or without surgical vascularization. Pre-operative computed tomography scans were performed to visualize the metatarsus and vasculature and to fabricate customized scaffolds and surgical guides by 3D printing. Critical-sized segmental defects created in the mid-diaphyseal region of the metatarsus were either left empty or treated with the 3D scaffold alone or in combination with an axial vascular pedicle. Bone regeneration was evaluated 1, 2 and 3 months post-implantation. After 3 months, the untreated defect remained non-bridged while the 3D scaffold guided bone regeneration. The presence of the vascular pedicle further enhanced bone formation. Histology confirmed bone growth inside the porous 3D scaffolds with or without vascular pedicle inclusion. Taken together, this pilot study demonstrated the feasibility of precised pre-surgical planning and reconstruction of large bone defects with 3D-printed personalized scaffolds.

Comparison of Osteochondral Autologous Transplantation and Dorsiflexion Closing Wedge Metatarsal Osteotomy for Late-Stage Freiberg Disease in Adults.

BACKGROUND: This study aimed to compare the clinical results between osteochondral autologous transplantation (OAT) and dorsiflexion closing wedge metatarsal osteotomy (DCWMO) in symptomatic adult patients with late-stage Freiberg disease. METHODS: Between 2012 and 2017, patients with late-stage Freiberg disease surgically treated with OAT (12 patients) or DCWMO (15 patients) were retrospectively identified. The American Orthopaedic Foot & Ankle Society-lesser metatarsophalangeal-interphalangeal (AOFAS-LMI) score, visual analog scale score for subjective pain, and range of motion (ROM) were determined preoperatively and at final follow-up. Postoperative complications were also recorded. RESULTS: The AOFAS-LMI score at final follow-up was significantly greater in the OAT group than in the DCWMO group (95.7 vs 87.9, P < .001), whereas plantarflexion at final follow-up was significantly lower in the DCWMO group than in the OAT group (30.0 vs 24.0 degrees, P = .037). The DCWMO group reported more postoperative complications including postoperative joint stiffness, deformity, and pain recurrence. In the OAT group, one patient complained of mild knee pain. CONCLUSION: OAT seemed a better procedure for late-stage Freiberg disease compared with DCWMO in adult patients in terms of postoperative functional score and ROM, with lower complication rates. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Freiberg's Infraction: Surgical Options.

Freiberg's infraction is an uncommon condition of the lesser metatarsophalangeal joints. Onset is usually between the 11th and 17th year of age. It is the only osteochondrosis that dominantly affects females with a reported female-to-male ratio of 5.1. The second metatarsal is most frequently involved (68%) followed by the third metatarsal (27%), and the fourth (3%). Surgical treatment options can be categorized in joint destructive and joint preserving procedures. Studies reveal complete resolution of pain and full return to activities in 70% after joint destructive procedure and more than 90% after joint preserving procedures.

Osteochondral Autologous Transplantation Versus Dorsal Closing Wedge Metatarsal Osteotomy for the Treatment of Freiberg Infraction in Athletes: A Randomized Controlled Study With 3-Year Follow-up.

BACKGROUND: Dorsiflexion closing wedge metatarsal osteotomy (DCWMO) has been considered the traditional treatment of Freiberg disease. Several case reports presented osteochondral autologous transplantation (OAT) as an alternative treatment. PURPOSE/HYPOTHESIS: The purpose was to compare the results of DCWMO versus OAT for the treatment of Freiberg infraction in an athletic population. It was hypothesized that OAT was superior to DCWMO regarding functional outcomes, pain, and the time that the athletes returned to training and to previous sport level. STUDY DESIGN: Randomized controlled trial; Level of evidence, 2. METHODS: Between 2008 and 2013, 27 consecutive patients with Freiberg disease were randomly assigned to either the DCWMO group (14 patients) or the OAT group (13 patients). The primary outcomes collected were as follows: postoperative complications, range of motion of the metatarsophalangeal joint, length of the metatarsal, function of the foot (measured with the American Orthopaedic Foot and Ankle Society-lesser metatarsophalangeal-interphalangeal [AOFAS-LMI] score), and pain (assessed with the visual analog scale-foot and ankle score). RESULTS: Mean follow-up was 46 months (range, 36-60 months). The mean ± SD AOFAS-LMI score in the DCWMO group was 63.4 ± 14.4 preoperatively, 81.8 ± 6.6 at 1 year postoperatively, and 84.4 ± 5.6 at 3 years postoperatively, while in the OAT group, it was 62.8 ± 14, 89.9 ± 7.1, and 92 ± 6.9, respectively (P < .001). The differences in the AOFAS-LMI scores favoring the OAT group at 1 and 3 years reached statistical but not clinical significance. The mean visual analog scale-foot and ankle score was improved significantly from 48.1 ± 11.5 to 91.8 ± 9.5 in the DCWMO group and from 49.9 ± 10.9 to 95.4 ± 4.4 in the OAT group. There was a shortening of the metatarsals by a mean 1.9 ± 0.5 mm in the DCWMO group, as opposed to a metatarsal lengthening of 0.2 ± 0.1 mm in the OAT group. In the OAT group, patients were able to start training at 6 ± 1 weeks (P < .001) and return to full sport action at 10 ± 2.5 weeks (P < .05), while in the DCWMO group, the time was 8 ± 1.5 and 13 ± 2.5 weeks, respectively. CONCLUSION: The authors concluded that OAT is equal to DCWMO. Acceptable clinical results were reported, as well as very low morbidity and early return to sport activities. That makes the OAT procedure a safe, effective, and optimal treatment for an athletic population experiencing Freiberg infraction.

Renal Function as a Predictor of Early Transmetatarsal Amputation Failure.

Chronic kidney disease (CKD) is a major concern in patients with foot disease because it is associated with high rates of neuropathy, peripheral vascular disease, and poor wound healing. The purpose of this study was to evaluate renal dysfunction as a risk factor for reamputation after initial transmetatarsal amputation (TMA). Patients who underwent a TMA were retrospectively identified in the American College of Surgeons National Surgical Quality Improvement Program database. Of 2018 patients, reamputation after TMA occurred in 4.4%. End-stage renal disease (ESRD) was associated with 100% increased odds of TMA failure (adjusted odds ratio [OR] = 2.00; 95% CI = 1.10, 3.52), 128% increased odds of major amputation (adjusted OR = 2.28; 95% CI = 1.27, 3.96), and 182% increased odds of 30-day mortality (adjusted OR = 2.82; 95% CI = 1.69, 4.64). In addition, white blood cell count >10 000/mm3 and deep infection at the time of surgery were independently associated with TMA failure. In conclusion, severe renal dysfunction is associated with TMA failure in the short-term, perioperative period. There was no incremental increase in risk of TMA failure with worsening level of renal function before ESRD. A multidisciplinary approach should be implemented in patients with CKD to prevent foot-related pathologies that may necessitate lower-extremity amputation. Levels of Evidence: Level III: Retrospective cohort study.

Functional Outcomes of Local Pedicle Graft Interpositional Arthroplasty in Adults With Severe Freiberg's Disease.

BACKGROUND: Conservative treatment or debridement is generally sufficient for Freiberg's disease grades I and II but operative intervention for the late stages of the disease process (III-V) is more challenging. Debridement alone is not sufficient and various forms of arthroplasty have been put forward. We have evaluated the outcomes of patients treated with an interpositional arthroplasty technique using a pedicle graft of periosteum and fat made into a "Rollmop" spacer for severe Freiberg's disease. No results have previously been reported for this technique. METHODS: Twenty-five consecutive cases (23 patients) were performed from February 2009 to September 2016 (20 females, 5 males). Mean age at surgery was 52.6 years (range 19-70.5 years) with 92% affecting the second metatarsal. Twenty-three were primary cases and 2 were revision cases. Five cases were stage III, 12 were stage IV, and 8 were stage V. All patients underwent interpositional arthroplasty using a periosteum and fat pedicle graft from the affected metatarsal shaft as described by Myerson. Patients were evaluated using Manchester-Oxford Foot Questionnaire (MOXFQ) and American Orthopaedic Foot & Ankle Society Questionnaire (AOFAS). Mean follow-up was 3.5 years (0.6-7.6 years). Paired 2-tailed Student t tests were used to assess clinical significance. RESULTS: Surgery allowed 8 patients to return to normal footwear, 10 patients returned to fashion footwear/heels, and 5 returned to sports. Nineteen cases (17 patients) were assessed with patient-reported outcome measures and all showed a clinically and statistically significant improvement in their scores. Mean pre- and postoperative VAS pain scores were 6.2 (range 4-9) and 1.8 (range 0-6) ( P < .05). Mean perioperative AOFAS scores were 45.6 (range 15-73) and 82.7 (range 57-100) ( P < .05). Mean perioperative MOXFQ scores were 60.0 (range 23-89) and 18.1 (range 0-80) ( P < .05). CONCLUSION: This novel interpositional arthroplasty technique using a "rollmop" of periosteum and fat for severe Freiberg's disease produced significant improvements in pain, functional outcome, and patient satisfaction without donor site morbidity. Furthermore, it allowed patients to return to desired footwear and sporting activities. The functional outcome and joint range of motion was superior after a K-wire was no longer placed across the joint, and we believe it is essential to avoid this to permit early range-of-motion exercises. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Three-Year Morbidity and Mortality Rates After Nontraumatic Transmetatarsal Amputation.

Patients requiring a nontraumatic transmetatarsal amputation (TMA) typically have multiple comorbidities that place them at high risk of postoperative complications and additional surgery. The present study identified the demographic, clinical, and surgical risk factors that predict complications after a nontraumatic TMA, including the incidence of 3-year mortality, proximal limb amputation, and lack of healing. The electronic medical records of patients who had undergone TMA within a Kaiser Permanente Northern California facility from March 2007 to January 2012 (n = 375) were reviewed. We used bivariate and multivariate analyses to examine the variations in the rates of TMA complications according to sex, age, race, and comorbid conditions, including nonpalpable pedal pulses, end-stage renal disease, coronary artery disease, hypertension, smoking status, and preoperative albumin <3.5 mg/dL. After a nontraumatic TMA, 136 (36.3%) patients had died within 3 years, 138 (36.8%) had required a more proximal limb amputation, and 83 (22.1%) had healed without complications. The patients with nonpalpable pedal pulses had 3 times the odds of requiring a proximal limb amputation (adjusted odds ratio [aOR] 3.07; 95% confidence interval [CI] 1.84 to 5.11), almost twice the odds of dying within 3 years (aOR 1.70; 95% CI 0.98 to 2.93), and >2 times the odds of not healing after the TMA (aOR 2.45; 95% CI 1.40 to 4.31). The patients with end-stage renal disease had 3 times the odds of dying within 3 years (aOR 3.10; 95% CI 1.69 to 5.70). The present findings can help us identify patients with an increased risk of postoperative complications after nontraumatic TMA, including patients with nonpalpable pedal pulses or end-stage renal disease, and suggest the vulnerability of this patient population.

[Gauthier's osteotomy and fixation using osteosuture in the treatment of Freiberg's disease]. / Ostéotomie de Gauthier et fixation par ostéo-sutures dans le traitement de la maladie de Freiberg.

Freiberg's disease is an osteochondrosis of the metatarsal heads mainly affecting the second metatarsal head. This study was conducted over a 3 year period. It reports 6 cases of patients, whose average age was 19.8 years, who had undergone Gauthier's dorsal subtraction osteotomy with fixation using osteosutures. The outcome of this technique was satisfactory. Indeed, the majority of patients had no pain and recovered normal daily activity. This study highlights that fixation using osteosutures is a reliable and inexpensive method.

Anatomic Limitations of the Transmetatarsal Amputation With Consideration of the Deep Plantar Perforating Branch of the Dorsalis Pedis Artery.

The transmetatarsal amputation is considered a durable procedure with respect to limb salvage when managing the consequences of diabetic foot disease. The success of the procedure is, in part, determined by the preoperative appreciation of arterial and functional status. The objectives of the present investigation were to determine the length of the remaining first metatarsal required during transmetatarsal amputation to preserve the anastomotic connection of the deep plantar perforating artery and subsequent "vascular arch" of the foot and the insertion of the tibialis anterior tendon. The primary outcome measure of our investigation was a measurement of the distance between the first metatarsal-medial cuneiform articulation and the distal extent of the deep plantar perforating artery in 85 embalmed lower limbs. As a secondary outcome measure, the insertion of the tibialis anterior tendon was evaluated relative to the deep plantar perforating artery. The most distal extent of the deep plantar perforating artery was observed at a mean ± standard deviation of 15.62 ± 3.74 (range 6.0 to 28.28) mm from the first metatarsal-medial cuneiform articulation. Most (89.41%) of the arteries were found within 20 mm of the first metatarsal-medial cuneiform articulation. The insertion of the tibialis anterior tendon was found to be proximal to the deep plantar perforating artery in all specimens (100.0%). In conclusion, 2.0 cm of remnant first metatarsal might represent an anatomic definition of how "short" a transmetatarsal amputation can safely be performed in most patients when considering the vascular and biomechanical anatomy.

[Amputation of the forefoot in a 14-year-old boy due to infiltrative glomus tumour].

Glomus tumours are rare dermal tumours, which very seldom can be seen viscerally. The majority is benign small tumours of the skin. Malignancy has been reported in very few cases worldwide. The diagnosis is made clinically supported by MRI-scans and biopsy of the lesion. We present a case story of a 14-year-old boy, who had an infiltrative glomus tumour of the foot. The tumour met the criteria for malignancy and was operated radically by amputation of the forefoot. The post-operative period was uncomplicated and no metastases were observed neither clinically nor by PET-CT scans.

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.

Combined Innovative Portal Arthroscopy and Fluoroscopy-Assisted Reduction and Fixation in Subtle Injury of the Lisfranc Joint Complex: Analysis of 10 Cases.

Subtle injuries of the Lisfranc joint complex are uncommon and difficult to diagnose clinically and thus are easily missed even by experienced orthopedic doctors. Misdiagnosed injuries can lead to chronic disability until eventual fusion surgery. We describe 10 cases diagnosed with subtle injury of the Lisfranc joint that were treated with combined innovative portal arthroscopy and fluoroscopy-assisted reduction and percutaneous screw fixation in an interfragmentary fashion. The distance between the first and second metatarsals (the Lisfranc distance) and that between the medial cuneiform and fifth metatarsal base (foot arch height) was measured before and after surgery. The American Orthopaedic Foot and Ankle Society function score was evaluated perioperatively. The average preoperative and postoperative Lisfranc distance was 4.38 ± 0.39 mm and 2.68 ± 0.9 mm, the foot arch height was 12.63 ± 2.75 mm and 21.80 ± 3.50 mm, and the American Orthopaedic Foot and Ankle Society score was 59.1 ± 5.69 and 86.8 ± 10.1, respectively. Of the 10 patients, 3 had excellent outcomes, 6 had good outcomes, and 1 had a fair outcome. In conclusion, we report a useful and minimally invasive surgery for acute, subacute, and even chronic subtle injury of the Lisfranc joint. The Lisfranc distance, foot arch height, and function of the foot were restored clinically, and all measurements showed statistically significant differences.