Introduction: The Distal metatarsal articular angle (DMAA) is a radiographic measure of orientation of the first metatarsal articular surface, it is frequently used in the management of hallux valgus. There is a great deal of conflict regarding accuracy, reproducibility and validity of the DMAA within the literature. This study aims to test the validity of the measurement of the DMAA from standard radiographs, to explore the trigonometric relationship of first metatarsal rotation and the DMAA and to assess inter-observer reliability. Materials/Methods: 34 seperate dry cadaveric first metatarsal bones were mounted onto a customized light-box/protractor allowing controlled incremental changes in rotation and inclination. A series of 39 digital photographs were taken of each metatarsal in 5 degree increments of rotation between 30 degrees supination and 30 degrees pronation and 10, 20 and 30 degrees of inclination. Three reviewers performed blinded DMAA measurements from each image; the data was collated for statistical analysis. Results: The data was analysed using a mixed effects linear model comparing the DMAA with rotation of the first metatarsal. A strong statistically significant trend of increasing score with increasing pronation is observed, the relationship of which is approximately linear. There is a strong effect of inclination, but the strength of this varies with rotation this is amplified at higher inclinations. Inter-observor error was noted in line with other studies, the linear relationship is maintained. Discussion: This study has shown that the distal metatarsal articular angle varies significantly, in an almost linear pattern, with axial rotation of the first metatarsal. Inclination of the first metatarsal is also shown to affect the magnitude of the angle. This study does not refute the distal metatarsal articular angle as an entity, but does confirm the inaccuracy of extrapolating the DMAA from plain AP radiographs

Introduction: The transverse metatarsal arch is the subject of some controversy as there isn’t a clear consensus as to whether there is a transverse arch (TMA) in stance phase. The current treatment options of forefoot pathology focus on the need to harmonise the TMA by the use of osteotomies such as the Weil osteotomy. Materials and Methods: A retrospective study of 75 feet (62 patients) with a mean follow up of 19 months. Patients underwent clinical, pedobarographic and radiological assessment. ‘Metatarsal skyline Views’ (MSV) were procured to assess the plantar profile of the TMA following Weil osteotomy. The feet were assessed using AOFAS, Foot Function Index, SF-36 and Manchester-Oxford Foot Questionnaires. Results: 69 feet showed good to excellent results with a normal MSV plantar profile. 6 feet had recurrent meta-tarsalgia with callosities and abnormal MSV profiles. These results correlated well with pedobarography. Discussion: The angle of Weil osteotomy is usually referenced relative to the floor irrespective of the plantar angulation of metatarsal. As different metatarsals had varying plantar angulations, the weight bearing metatarsal skyline view was used to ascertain the plantar profile of the metatarsals before, during and after surgery. This was also used to determine the amount of dorsal displacement required in addition to shortening in order to harmonise both length and plantar profile. Conclusion: The use of the Metatarsal skyline view has significantly improved our planning of the angles of the Weil osteotomy.We suggest that the reference for the osteotomy should be the plantar angulation of the metatarsal rather than the floor. It has made the intra-operative assessment of the osteotomy easier and has improved our understanding of the osteotomy and its influence on the forefoot plantar profile

Introduction: The transverse metatarsal arch is the subject of some controversy as there isn’t a clear consensus as to whether there is a transverse arch (TMA) in stance phase. The current treatment options of forefoot pathology focus on the need to harmonise the TMA by the use of osteotomies such as the Weil’s. Materials and Methods: A retrospective study of 75 feet (62 patients) with mean follow up of 19 months. Patients underwent clinical, pedobarographic and radiological assessment. ‘Metatarsal skyline Views’ (MSV) were procured to assess the plantar profile of the TMA following Weil osteotomy. The feet were assessed using AOFAS, Foot Function Index, SF-36 and Manchester-Oxford Foot Questionnaires. Results: 69 feet showed good to excellent results with a normal MSV plantar profile. 6 feet had recurrent metatarsalgia with callosities and abnormal MSV profiles. These results correlated well with pedobarography. Discussion: The angle of Weil osteotomy is usually referenced relative to the floor irrespective of the plantar angulation of metatarsal. As different metatarsals had varying plantar angulations, the weight bearing metatarsal skyline view was used to ascertain the plantar profile of the metatarsals before, during and after surgery. This was also used to determine the amount of dorsal displacement required in addition to shortening in order to harmonise both length and plantar profile. Conclusion: The use of the Metatarsal skyline view has significantly improved our planning of the angles of the Weil osteotomy. We suggest that the reference for the osteotomy should be the plantar angulation of the metatarsal rather than the floor. It has made the intraoperative assessment of the osteotomy easier and has improved our understanding of the osteotomy and its influence on the forefoot plantar profile

Introduction. Recurrence after surgical correction of hallux valgus may be related to coronal rotation of the first metatarsal. The scarf osteotomy is a commonly used procedure for correcting hallux valgus but has limited ability to correct rotation. Using weightbearing computed tomography (WBCT), we aimed to measure the coronal rotation of the first metatarsal before and after a scarf osteotomy, and correlate these to clinical outcome scores. Methods. We retrospectively analyzed 16 feet (15 patients) who had a WBCT before and after scarf osteotomy for hallux valgus correction. On both scans, hallux valgus angle (HVA), intermetatarsal angle, and anteroposterior/lateral talus-first metatarsal angle were measured using digitally reconstructed radiographs. Metatarsal pronation (MPA), alpha angle, sesamoid rotation angle and sesamoid position was measured on standardized coronal CT slices. Preoperative and postoperative(12 months) clinical outcome scores(MOxFQ and VAS) were captured. Results. Mean HVA was 28.6±10.1 degrees preoperatively and 12.1±7.7 degrees postoperatively. Mean IMA was 13.7±3.8 degrees preoperatively and 7.5±3.0 degrees postoperatively. Before and after surgery, there were no significant differences in MPA (11.4±7.7 and 11.4±9.9 degrees, respectively; p = 0.75) or alpha angle (10.9±8.0 and 10.7±13.1 degrees, respectively; p = 0.83). There were significant improvements in SRA (26.4±10.2 and 15.7±10.2 degrees, respectively; p = 0.03) and sesamoid position (1.4±1.0 and 0.6±0.6, respectively; p = 0.04) after a scarf osteotomy. There were significant improvements in all outcome scores after surgery. Poorer outcome scores correlated with greater postoperative MPA and alpha angles (r= 0.76 (p = 0.02) and 0.67 (p = 0.03), respectively). Conclusion. A scarf osteotomy does not correct first metatarsal coronal rotation, and worse outcomes are linked to greater metatarsal rotation. Rotation of the metatarsal needs to be measured and considered when planning hallux valgus surgery. Further work is needed to compare postoperative outcomes with rotational osteotomies and modified Lapidus procedures when addressing rotation

[Objectives] Hallux valgus, dorsal sublaxation or dislocation of metatarsophalangeal joints and clawing of the lateral toes are seen frequently in patients with rheumatoid arthritis (RA). Resection arthroplasty of the metatarsophalangeal joints (MTP joints) are widely used to correct these forefoot deformities and the clinical results are almost good. However lateral toes tend to displace dorsally and painful callosity tends to recur. We used the metatarsal shortening offset osteotomy for shortening and dorsal/medial displacement of the prominent metatarsal head. In this report, we introduce the surgical techniques of shortening offset osteotomy and postoperative changes of plantar pressure measured with F-scan system (Tekscan, Inc. ), and review the short term result during 1 to 4 year follow-up. [Materials and Methods] This study involved 26 feet of 18 patients with RA which were performed with the metatarsal osteotomy for lateral toes and followed more than 1 year (average follow-up 29 months, range 14–46 months). The average age of the 17 women and 1 man was 61 years (range, 51–77 years). The mean duration from the onset of RA to operation on the forefoot was 17 years (range, 7–42 years). Skin incision was placed on the dorsum of the foot and the extensor digitorum brevis and longus were severed (or elongated). After reposition of MTP joint, transverse osteotomy of distal fifth of the lateral metatarsal bone was performed with resection of few millimeters length metaphysial bone. Cortical bone of the distal end of the proximal stump was chiseled into a small rod between two ditches with rongeur and then the rod was put into medullary canal mortise of distal stump. This procedure make offset shift of metatarsal head medially or dorsally. Swanson implant arthroplasty, distal osteotomy was performed on the great toe. Postoperative clinical and radiological results were evaluated with AOFAS rating system. We measured dynamic plantar pressure before and one year after operation in one representative case. [Results] At the time of follow-up, the mean AOFAS score was 80 points (59–95) and the mean pain score was 36 points. The recurrence of painful callosity was one case. Nevertheless, the range of motion of the MTP joint remained low: 30 degrees and less in 16 feet (62%) including 3 bony ankylosis of MTP joints. There was no nonunion case. [Discussion]. Resection arthroplasty has been accepted as the treatment of choice for forefoot deformities in RA patients. Recent advance of drug therapy against RA encouraged us to preserve the joint in correction of forefoot deformities. Our technique aimed at preservation of the function of the MTP joints and is suitable for mild deformities in which only one or two rays are involved. Furthermore it is easy to correct the deformity of spray foot and reduce the plantar prominence of metatarsal head. This study revealed the good clinical result in short term follow-up. Although the long term result must to be waited, this method is one of recommendable options for RA patients with forefoot deformities

Background: The occurrence of congenitally short metatarsals is associated with an abnormal gait and an aesthetically displeasing appearance. Similarly, short metacarpals result in severe cosmetic disfigurement, particularly in young female patients. Methods: We examined and performed bone lengthening surgery in 13 female and 2 male patients. Of these, procedures were conducted on 12 metatarsals of 8 patients, 4 metacarpals and 1 metatarsal of a single patient, 1 metacarpal and 1 metatarsal of a single patient and 7 metacarpals of 5 patients. The mean age of the patients who underwent metacarpal procedures was 14.5 (10–21) years while the mean age of those who underwent metatarsal procedures was 17.5 (10–25) years. The callotasis method was employed for these procedures and we used either a unilateral external fixator and/or a circular external fixator. Results: The mean healing index and increase in metacarpal length was 1.6 (1.1–2.3) months/cm and 17.6 (13–26) mm, respectively. The mean follow-up period for patients who underwent metacarpal lengthening was 57.5 (12–96) months. The mean healing index and increase in metatarsal length was 1.6 (1.0–2.0) months/cm and 24.3 (20–30) mm respectively. The mean follow-up period for patients who underwent metatarsal lengthening was 48.3 (12–72) months. The preoperative AOFAS (American Orthopaedic Foot and Ankle Society) scores were good in 5 and excellent in 9 cases. The functional scores of metatarso-phalangial (MTP) joint of lengthened metatarsals for the lesser toe were excellent in 12 and good in 2 cases based on the AOFAS scoring system. All patients who underwent metacarpal lengthening reported that they were satisfied and could conduct their daily activities with good functional and aesthetic results. Complications included 4 angulations, 1 subluxation and 1 non-union and were seen in 6 of the metatarsal lengthening cases that exceeded 40% (or > 20 mm) of the total length of the original bone. Interpretation: There are recommendations in the literature that allow for the avoidance of severe complications and for the shortening of the consolidation period. We conclude that the periosteum must be protected with percutaneus osteotomy and lengthening should be performed at a rate of 0.25 mm twice a day, should not exceeding 40% of the original bone length (or > 20 mm). If the anticipated lengthening exceeds these predefined values then we suggest that the procedure should be performed using a circular external fixator with temporary fixation of the MCP or the MTP joint and the inclusion of the proximal phalanx in the frame

Acute metatarsal fractures are a common extremity injury. While surgery may be recommended to reduce the risk of nonunion or symptomatic malunion, most fractures are treated with nonoperative management. However, there is significant variability between practitioners with no consensus among clinicians on the most effective nonoperative protocol, despite how common the form of treatment. This systematic review identified published conservative treatment modalities for acute metatarsal fractures and compares their non-union rate, chronic pain, and length of recovery, with the objective of identifying a best-practices algorithm. Searches of CINAHL, EMBASE, MEDLINE, and CENTRAL identified clinical studies, level IV or greater in LOE, addressing non-operative management strategies for metatarsal fractures. Two reviewers independently screened the titles, abstracts, and full texts, extracting data from eligible studies. Reported outcome measures and complications were descriptively analyzed. Studies were excluded if a rehabilitation program outlining length of immobilization, weight-bearing and/or strengthening approaches was not reported. A total of 12 studies (8 RCTs and 4 PCs), from the 2411 studies that were eligible for title screening, satisfied inclusion criteria. They comprised a total of 610 patients with acute metatarsal fractures, with a mean age of 40.2 years (range, 15 – 82). There were 6 studies that investigated avulsion fractures, 2 studies on true Jones fractures, and 4 studies with mixed fracture types. Studies assessed a variety of treatment modalities including: WB and NWB casts, elasticated support bandages, hard-sole shoes, plaster slippers, metatarsal shoe casts, and air cast boots. Most studies investigated the outcomes of NWB casts and elasticated support bandages. The NWB short leg cast had no reported non-unions, delayed-unions, or refractures for avulsion fractures. In true Jones fractures, there was an average non-union rate of 23.6% (range, 5.6 – 27.8%), delayed-union rate of 11.8% (range, 5.6 – 18.8%), and refracture rate of 3% (range, 0 – 5.6%). Overall, the average AOFAS score was 87.2 (range, 84 – 91.7) and the average VAS score was 83.7 (range, 75 – 93). The elasticated support bandage had an average non-union rate of 3.4% (range, 0 – 12%), and delayed-union rate of 3.8% for acute avulsion fractures, with no reported refractures. No included study arm investigated outcomes of elasticated support bandages for the true Jones fracture. The average AOFAS score for elasticated support bandages was 93.5 (range, 90 – 100). The average VAS score was 88.9 (range, 90 – 100). Most acute metatarsal fractures heal well, with good-to-excellent functional outcomes and moderate-to-high patient satisfaction. Conservative strategies for avulsion fractures are highly successful and based on this data the authors recommend patients undergo a schedule that involves 3 – 4 weeks in an elasticated support bandage, short leg cast, or equivalent, and WB thereafter as tolerated, with return-to-activity after clinical union. Despite poorer conservative outcomes for true Jones fractures, patients should undergo 8 weeks in a NWB short leg cast, followed by a walking cast or hard-sole shoe for an additional 4 – 6 weeks, or until clinical union. However, surgical consultation is recommended

One of the complications of hallux valgus surgery is shortening of the first metatarsal and this becomes particularly symptomatic in patients with a pre existing short metatarsal (Morton's foot or Greek foot). Initial treatment consists of appropriate insoles which incorporate not only relief of pain due to pressure metatarsalgia under the lesser metatarsal heads but also a Morton type extension under the big toe. Insoles with metatarsal relief are, however, not always well tolerated and surgery becomes necessary. The options are to shorten the lesser metatarsal heads or lengthen the previously shortened first metatarsal. Arthrodesis of the great toe metatarso-phalangeal joint can provide functional length to the first metatarsal. We have achieved good results in lengthening of the first metatarsal and believe that it is a safe option which avoids trauma to the lesser metatarso-phalangeal joints. The technique is presented and depends on whether there is a residual hallux valgus or whether the toe is well aligned. The operation should address the plane of the deformity and reverse the cause of the lengthening. Emphasis should however be placed in not getting the complication in the first instance and the incidence of the problematic short first metatarsal has significantly reduced since the decrease in popularity of the Wilson osteotomy

Metatarsalgia is a recognised complication following iatrogenic shortening of the first metatarsal in the management of hallux valgus. The traditional surgical treatment is by shortening osteotomies of the lesser metatarsals. We describe the results of lengthening of iatrogenic first brachymetatarsia in 16 females. A Scarf-type osteotomy was used in the first four cases and a step-cut of equal thicknesses along the axis of the first metatarsal was performed in the others. The mean follow-up was 21 months (19 to 26). Relief of metatarsalgia was obtained in the six patients in whom 10 mm of lengthening had been achieved, compared to only 50% relief in those where less than 8 mm of lengthening had been gained. One-stage step-cut lengthening osteotomy of the first metatarsal may be preferable to shortening osteotomies of the lesser metatarsals in the treatment of metatarsalgia following surgical shortening of the first metatarsal

We reviewed the outcome of distal chevron metatarsal osteotomy without tendon transfer in 19 consecutive patients (19 feet) with a hallux varus deformity following surgery for hallux valgus. All patients underwent distal chevron metatarsal osteotomy with medial displacement and a medial closing wedge osteotomy along with a medial capsular release. The mean hallux valgus angle improved from −11.6° pre-operatively to 4.7° postoperatively, the mean first-second intermetatarsal angle improved from −0.3° to 3.3° and the distal metatarsal articular angle from 9.5° to 2.3° and the first metatarsophalangeal joints became congruent post-operatively in all 19 feet. The mean relative length ratio of the metatarsus decreased from 1.01 to 0.99 and the mean American Orthopaedic Foot and Ankle Society score improved from 77 to 95 points. In two patients the hallux varus recurred. One was symptom-free but the other remained symptomatic after a repeat distal chevron osteotomy. There were no other complications. We consider that distal chevron metatarsal osteotomy with a medial wedge osteotomy and medial capsular release is a useful procedure for the correction of hallux varus after surgery for hallux valgus

We analysed the clinical and radiological outcomes of a new surgical technique for the treatment of heterozygote post-axial metatarsal-type foot synpolydactyly with HOX-D13 genetic mutations with a mean follow-up of 30.9 months (24 to 42). A total of 57 feet in 36 patients (mean age 6.8 years (2 to 16)) were treated with this new technique, which transfers the distal part of the duplicated fourth metatarsal to the proximal part of the fifth metatarsal. Clinical and radiological assessments were undertaken pre- and post-operatively and any complications were recorded. Final outcomes were evaluated according to the methods described by Phelps and Grogan. Forefoot width was reduced and the lengths of the all reconstructed toes were maintained after surgery. Union was achieved for all the metatarsal osteotomies without any angular deformities. Outcomes at the final assessment were excellent in 51 feet (89%) and good in six (11%). This newly described surgical technique provides for painless, comfortable shoe-wearing after a single, easy-to-perform operation with good clinical, radiological and functional outcomes. Cite this article: Bone Joint J 2013;95-B:929–34

Purpose of the study: Bipolar dislocation of the first metatarsal, also called floating metatarsal, remains a rare traumatic injury of the first ray of the foot. This is an acute unstable post-traumatic metatarsophalangeal and cuneometatarsal injury occurring simultaneously or successively. Most earlier reports have been single case reports. We report here three successive cases in adults to study the mechanism of the injury, the clinical forms and the different therapeutic modalities. Material and method: The patients were three males aged 35 years on average who presented a bipolar dislocation of the first metatarsal. Results: The causal event was an automobile accident for two patients and a work accident for one. There was an open wound in two cases over the metatarsophalangeal joint. Orthopaedic metatarsophalangeal reduction was achieved in two cases and open cuneometarsal reduction in one. The cuneometatarsal reduction was maintained with a pin for six weeks. The auto-reduction was then continued. Discussion: Described for the first time by English as a paired dislocation, in 1997 Liebner coined the term of a floating metatarsal. We were able to identify eight publications in the literature. The causal mechanism would be successive dislocation of themetatarsophalangeal joint first followed by the cuneometatarsal joint. The metatarsophalangeal dislocation was dorsal in two patients and lateral in one. The sesamoid girdle remained intact (Jahns 1) and in all cases followed the first phalanx in its displacement (Garcia Mata S+). The cuneometatarsal dislocation was dorsal in all cases. The skin opening involved the plantar surface in one case and was medial in the other, allowing externalisation of the first metatarsal head. The floating metatarsal was isolated in one case and associated with a fracture of the second metatarsal in two. Primary reduction of the metatarsophalangeal joint then the cuneometatarsal joint was achieved in all cases. Irreducibility due to a button effect was noted in one case. At minimum three months follow-up, there has been no evidence of deformity. The foot has remained pain free with correct shoe wearing. The control x-rays have not shown any subluxation. Conclusion: The floating first metatarsal is an exceptional foot injury. Primary reduction of the metatarsophalangeal joint appears to be the rule. Adequate primary treatment ensures satisfactory outcome

We studied a cohort of 26 diabetic patients with chronic ulceration under the first metatarsal head treated by a modified Jones extensor hallucis longus and a flexor hallucis longus transfer. If the first metatarsal was still plantar flexed following these two transfers, a peroneus longus to the peroneus brevis tendon transfer was also performed. Finally, if ankle dorsiflexion was < 5° with the knee extended, a Strayer-type gastrocnemius recession was performed. The mean duration of chronic ulceration despite a minimum of six months’ conservative care was 16.2 months (6 to 31). A total of 23 of the 26 patients were available for follow-up at a mean of 39.6 months (12 to 61) after surgery. All except one achieved complete ulcer healing at a mean of 4.4 weeks (2 to 8) after surgery, and there was no recurrence of ulceration under the first metatarsal. We believe that tendon balancing using modified Jones extensor hallucis longus and flexor hallucis longus transfers, associated in selected cases with a peroneus longus to brevis transfer and/or Strayer procedure, can promote rapid and sustained healing of chronic diabetic ulcers under the first metatarsal head

Introduction: One of the complications of first metatatarsal osteotomies is metatarsalgia secondary to shortening of the first metatarsal. Conservative treatment with insoles is not acceptable to all patients and the traditional treatment of this condition is by shortening osteotomies of the lesser metatarsals (eg Weil, Helal)- the latter osteotomies themselves have complications of causing pain or stiffness in the lesser toes. Purpose: The aim of this work is to report our results of step cut metatarsal lengthening of iatrogenic first brachymetatarsia. Patients and Methods: 16 female patients had metatarsal lengthening of iatrogenic first brachymetatarsia. A typical Scarf type osteotomy was used in the first 4 cases and a simple step cut of equal thicknesses along the axis of the first metatarsal was performed in the next 12 procedures. Results: When 10mm lengthening was done, the metatarsalgia was relieved in all of the 6 patients, in contrary to only 50% relief of symptoms in the patients when less then 8mm lengthening was achieved. Conclusions: One stage step cut lengthening osteotomy of the iatrogenic short first metatarsal, when over 8mm length is achieved, is safe with good results and is a preferable alternative to shortening osteotomies of the lesser metarsals in the treatment of metarsalgia due to inappropriate shortening of the first metatarsal

Purpose of the study: Osteotomy of the first metatarsal has become the gold standard treatment for hallux valgus. We report a study on the changes in radiographic findings as a function of the degree of translation of the distal fragment of the metatarsal during scarf distal wedge osteotomy. Material and methods: From the cohort of patients who underwent hallux valgus surgery in our unit, we collected 118 anteroposterior x-rays of the forefoot. Computer-assisted image processing established a trigonometric analysis of each forefoot before and after standardised virtual surgery. Variations in standard morphological measurements (phalangeal valgus: M1P1; metatarsal varus: M1M2; orientation of the joint surfaces of the first metatarsal: proximally (PMAA) and distally (DMAA). Results: The successive translations significantly modified all of the morphological measurements. For M1M2, intermediary translation corrected the metatarsal varus (< 5) in 72% of the cases, maximal translation in 97%. For the M1P1 angle, intermediary translation only corrected the phalangeal valgus (< 8) in 44% of cases, maximal translation in 31%. For the DMAA angle, intermediary translation corrected the distal articular orientation (< 6) in 66%, maximal translation in 97%. Distal translation of the first metatarsal aggravated the obliquity of the proximal joint surface from a mean 1.57±4.5 to 7.7±4.7, with intermediary translation and to 13.92±4.9 with maximal translation. Discussion: Considering the large number of techniques proposed, the choice of one osetotomy model is reductive, but it does demonstrate via a geometric application the limits of osteotomy translation of the first metatarsal for the correction of hallux valgus

Background and objective. Metatarsals stress fractures are common in athletes and dancers. Occasionally, such fractures could occur without trauma in peripheral neuropathic patients. There is no published series describing outcome of stress fractures in these patients. This study analyse these fractures, treatment and outcome. Material and Method. Retrospective study, January 2005 to December 2010. From a total of 324 patients with metatarsal fractures, 8 patients with peripheral neuropathy presented with second metatarsal non-traumatic fractures. Fractures were initially treated in cast for more than three months but failed to heal. Subsequently, this led to fractures of 3rd, 4th and 5th metatarsals. All patients remained clinically symptomatic due to fracture non-union. Operative treatment with bone graft and plating was used. Postoperatively below knee plaster and partial weight bearing for 12 weeks. Clinical and radiological surveillance continued until bone union. Results. There were 2 male and 6 female patients, age (24–83). 22 metatarsals had clinical and radiological union. 1 patient needed 1st tarsometatarsal joint fusion along with metatarsals fractures fixation. This patient developed deep infection and required below knee amputation. 2 patients required metalwork removal. Patient's satisfaction score was 8/10. Conclusion. Our review suggests low energy metatarsal stress fractures treated nonoperatively provide limited success. Timely surgical intervention and internal fixation proved to be a valid treatment option

Some patients following operation for Hallux Valgus deformity develop Transfer Metatarsalgia. Many believe that a long oblique osteotomy of the second metatarsal as part of surgical correction of Hallux Valgus deformity reduces the risk of developing transfer metatarsalgia. Metatarsal Break Angle (MBA) is the angle subtended by one line from the centre of the head of First Metatarsal to the centre of the head of the Second Metatarsal and another from the centre of the head of the Second Metatarsal to the centre of the head of Fifth Metatarsal. The MBA changes following osteotomy of the Second metatarsal. Is the Metatarsal Break Angle(MBA) altered in patients who undergo long oblique osteotomy of the second metatarsal?. Literature does not mention anything to this effect. We prospectively studied the course of this angle in patients who underwent osteotomy of the second metatarsal at the same time as they had surgical correction of their painful Hallux Valgus deformity. Twenty-four consecutive patients (thirty-one feet), nineteen Female and five Male, in the age range of eighteen to seventy-one years successfully fulfilled the inclusion criteria. The inclusion criteria being - Hallux Valgus deformity with a dorsally subluxed second Meta-tarsaophalangeal joint(MTPJ) and presence of tenderness/hyperkeratotic plantar patch at the second MTPJ. The postoperative range of increase in the angle was two to sixteen degrees in all except one patient (decreased by one degree). Median change was eight degree increase. This study concludes that the MBA is altered in patients who undergo long oblique osteotomy of the second metatarsal. This type of osteotomy done so as to provide the head of the second metatarsal a fresh plantar fat pad to rest upon does help to remove the tenderness over the second MTPJ. To the best of our knowledge this change in MBA has not been mentioned in the medical literature and we believe that our study highlights this important geometrical change in the architecture of post-operative forefoot

Aims: The weight distribution pattern of the metatarsal heads has been a controversial issue in orthopaedics. In this study, we have investigated the weight distribution pattern of the metatarsal heads and their relationship between static radiographic measurements. Methods: Both feet of 60 healthy young volunteer subjects were examined. Forefoot pressures were recorded by using EMED-SF (Novel, Germany). The mean and peak pressures of the metatarsal heads were recorded during the midstance and push-off phases of the gait cycle. From the AP and lateral radiogram we have determined the metatarsal index, Morton and Stokes ratios, talometa-tarsal and talohorizontal angles. Results: The peak and mean pressures of þrst and second metatarsals during push off and mid stance phases of the gait cycle was found to be correlated with metatarsal index and Mortonñs ratios. There was no correlation between the pressure difference of þrst and second metatarsals and the static radiographic parameters. Discussion: The relative length ratios of the þrst and second metatarsal lengths are considered mostly for the different metatarsal pressure patterns. In this study although we have found that the pressure under the þrst metatarsal head was related with the static measurements, the difference between þrst and second metatarsal pressures was not found to be correlated with static measures. We concluded that the pressure difference of second and þrst metatarsal heads could not be simply determined using static measurements from the radiograms of the foot

Introduction. Brachymetatarsia is a rare deformity affecting the toes and leading to functional and psychological impact. The main aim of the study is to assess the efficacy of the surgical callus distraction technique in terms of length achievement in the paediatric group. Secondary objectives are functional improvement, reported complications and overall duration of treatment. Materials and Methods. For the series of cases involving all paediatric patients who had surgical correction at our unit from 2014 until the present, the electronic records were accessed to collect data. Pre-, peri- and post-operative assessments and investigations were used to evaluate patients' progress. The final plain films obtained were used to calculate the overall length achieved. Results. Six patients (ten feet) have been identified since 2014 with 12 metatarsals being gradually lengthened by applying the callus distraction principle using MiniRail OrthoFix 100. The majority are females (n=5), all of whom were diagnosed with congenital brachymetatarsia, with the only male (n=1) being post-traumatic, while the mean age is 14.5 ±1.5. The treatment was successful in all cases, with an average duration between surgery and metal removal of 5.5 ±1.3 months. Gait lab analysis was performed in (n=2) patients as part of preoperative analysis supporting surgical intervention. Complications were reported in two toes, with one requiring a revision procedure for loss of tension at the osteotomy site, and the second having an infected MTPJ stabilising k-wire treated with oral antibiotics and planned removal. Conclusions. In the paediatric group, gradual MT lengthening surgery using the Mini Ex-Fix is an effective method to treat brachymetatarsia. Preoperative assessment, psychological support and preparation for the extended rehabilitation period are vital. Gait lab analysis is advised pre- as well as postoperatively and this is now our protocol for supporting surgical decision

Introduction: Distal osteotomy of the first metatarsal is indicated in the surgical treatment of mild-to-moderate hallux valgus deformity. The aim of this study was to evaluate the results of a subcapital distal osteotomy of the first metatarsal using a percutaneous technique. Methods: From 1996 to 2001 118 consecutive percutaneous distal osteotomies of the first metatarsal were performed in 82 patients for the treatment of painful mild-to-moderate hallux valgus. Patients were assessed at a mean follow-up of 35.9 months employing a clinical and radiographic protocol. The American Orthopedic Foot and Ankle Society’s hallux-metatarsophalangeal-interphalangeal scale was used for the clinical assessment. Results: in 107 of the 118 cases (90.7%), patients were satisfied with the procedure. The mean score obtained in the clinical assessment using the AOFAS scale was 88.2 ± 12.9. The radiographic assessment showed significant changes (P< 0.05) in the values of the hallux valgus angle, first intermetatarsal angle, distal metatarsal articular angle and the sesamoid position at the postoperative assessment compared to preoperative values. Recurrence of the valgus deformity was observed in 3 cases (2.5%), non-painful stiffness of the first metatarsophalangeal joint in 7 (5.9%) and a deep infection resolved by antibiotic therapy in 1 (0.8%). Conclusions: The percutaneous procedure proved to be a reliable technique for the correct execution of a distal linear osteotomy of the first metatarsal for the correction of painful mild-to-moderate hallux valgus deformity. The clinical results appear to be comparable to those obtainable with the traditional open techniques, with the additional advantages of a minimally invasive procedure, substantially shorter operating times and a reduced risk of complications related to surgical exposure