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

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

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

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

In recent years the Weil osteotomy has become the dominant technique employed by most surgeons for distal metatarsal osteotomy. This is generally a reliable technique but problems with stiffness can frequently occur in the operated metatarso-phalangeal joints. We present our experience with a minimally invasive distal metatarsal extra-articular osteotomy technique. This technique utilises a high-speed burr via a tiny skin portal to perform a distal metatarsal extra-articular osteotomy under image intensifier guidance without the need for fixation. A consecutive series of 55 osteomies in 21 patients were included in the study. All osteotomies were performed for metatarsalgia/restoration of metatarsal cascade. The mean age was 49 (38-78), and 20/21 were female. The senior author performed all surgery. All patients were allowed to weight bear immediately in a postoperative shoe and then an ordinary shoe from 4-6 week post-operatively. Mean follow-up was 8 months (4-13) and patients were assessed clinically and scored using the AOFAS scoring system and a subjective outcome score. The mean AOFAS score improved significantly postoperatively. All patients were very satisfied/satisfied with the outcome. Two patients had minor superficial portal infections, which resolved with oral antibiotics. One patient reported irritating numbness and stiffness in toes (1st case performed). Most patients reported swelling persisting to 3-4 months. There was one symptomatic delayed at 4 months treated successfully with short air boot immobilisation. There were no mal unions. This series suggests that MIS distal metatarsal osteotomy results compare well with outcomes reported with modern open techniques such as the Weil. We now favour an MIS distal metatarsal osteotomy technique for most indications due to the minimal stiffness observed postoperatively as well as much reduced surgical time without the need for tourniquet

Introduction:. The surgical treatment of intractable metatarsalgia has been traditionally been an intra-articular Weil's type of metatarsal osteotomy. In such cases, we adopted the option of performing a minimally invasive distal metaphyseal metatarsal ostetomy (DMMO) to decompress the affected ray. The meta-tarsophalangeal joint was not jeopardised. We present our outcomes of Minimally Invasive Surgery for metatarsalgia performed at our teaching hospital. Material and methods:. This is a multi-surgeon consecutive series of all the thirty patients who underwent DMMO. The sex ratio was M: F- 13:17. Average age of patients was 60 yrs. More than one metatarsal osteotomy was done in all cases. The aim was to try and decompress the affected rays but at the same time, restore the metatarsal parabola. It was performed under image-intensifier guidance, using burrs inserted via stab incisions. Patients were encouraged to walk on operated foot straight after the operation; the rationale being that the metatarsal length sets automatically upon weight bearing on the foot. Outcome was measured with Manchester-Oxford Foot Questionnaire's (MOXFQ's) and visual analogue pain score (VAS). Minimum follow up was for six months. Results:. The average MOXFQ score was 26. Average improvement in the visual analogue pain score was 3.5. VAS deteriorated in three patients' whose pain got worse after surgery. Among these three, two had a further procedure on their toes. All of the patients experience prolonged forefoot swelling for at least 3 months. Discussion:. The most common complication after intra-articular ostetomy of the metatarsal head is stiffness of the metatarsophalangeal joint. We believe that using minimally invasive surgery with an extra-articular osteotomy, reduces the soft tissue injury to the joint, and therefore the amount of post-operative stiffness. In our cohort of patients, DMMO is associated with good patient satisfaction and low complication rates in the vast majority of cases

Metatarsal fractures are extremely common injuries accounting for 10% of all fractures seen in our accident and emergency departments (3). The vast majority can be treated conservatively. There is no standardised treatment, but it is commahplace to immobilise the foot and ankle joint in a below-knee back-slab, full cast or functional brace for a period of up to 6 weeks, weight-bearing the patient as pain allows. This practice is time-consuming and expensive, not to mention debilitating, and carries a morbidity risk to the patient. We describe a simple, effective and cheap treatment method for metatarsal fracture management using the functional forefoot-offloading shoe (FOS). This is clinically proven to offload pressure on the metatarsals and is commonly used in both elective forefoot surgery and in diabetic patients. Between January and September 2009, we identified 57 patients attending our fracture clinic with new metatarsal fractures. 28 met our inclusion criteria. All patients reported a significant improvement in their pain. At Injury – mean 8.21 out of 10 (range 4-10). After FOS fitting - mean 2.92 out of 10 (range 0-6). The forefoot-offloading shoe is an excellent alternative to plaster casting or functional boot immobilisation, offering high patient satisfaction, an excellent outcome and a considerable cost-saving to the hospital trust

Introduction. Hallux valgus deformity is a common potentially painful condition. Over 150 orthopaedic procedures have been described to treat hallux valgus and the indication for surgery is pain intractable to nonoperative management. Methods. A retrospective analysis of the treatment of complex hallux valgus with bifocal metatarsal and Akin osteotomies of the first ray performed by the senior author (CC). 22 patients were treated over a three year period from 2008 to 2011, 24 trifocal osteotomies were undertaken. Hallux valgus angle (HVA), intermetatarsal angle (IMA) and distal metatarsal articular angle (DMAA) were all measured from pre- and postoperative radiographs. The patients were also clinically reviewed. Results. The study group consisted of 21 women and 1 man with a mean age of 53 years. The average time to follow up was 19 months. Four cases had undergone previous surgery. Average HVA correction was 26.9 degrees (p < 0.0001), average IMA correction was 12.65 degrees (p < 0.0001). No patients had postoperative infection and all osteotomies went on to union. All patients reported resolution of pain. Two patients required removal of metalwork and the distal osteotomy angulated slightly in one patient not requiring reoperation. Conclusion. We demonstrate that bifocal metatarsal and akin osteotomies of the first ray are a safe and effective method of correcting complex hallux valgus

Background & aim. There have been many operations described for the treatment of hallux valgus deformities and b ette done separately with variable success rates. Our aim is to radiologically assess the outcome following simultaneous osteotomies to the 1st and 5th metatarsals in symptomatic patients with splay foot. To our knowledge, this procedure has not been described in the literature yet. Materials & method. 9 symptomatic patients (12 feet) were included in the study. The pre-operative and post-operative X-rays were assessed and the hallux valgus angles, 1st and 2nd intermetatarsal angles, distal metatarsal articular angles (DMAA), 4th and 5th intermetatarsal angles, maximum widths of the 1st and 5th metatarsal heads and the maximum distance between 1st and 5th metatarsals were calculated. The improvement in the angles and distances post-operatively were then assessed for statistical significance using Non-parametric paired T tests. Results. Hallux valgus angles (pre op mean of 28.17o (range, 20o-40o), post-op. mean of 16.33o (range, 4o-30o)), inter-metatarsal angles (mean of 14o (range, 9o-20o) and a post-op. mean of 9.29o (range, 4o-14o)), 1st and 5th metatarsal head widths (pre-op mean of 2.27cm and 1.27cm respectively and a post-op. width of 1.87cm and 1.09cm respectively), and maximum distance between 1st and 5th metatarsals head (pre-op mean of 8.05cm (range, 7.4cm-9.1cm) and post-op mean of 7.15cm (range, 6.8cm-7.7cm) all have significantly decreased post-operatively (p< 0.05). Conclusion. The results suggest a very good outcome in symptomatic patients following simultaneous 1st and 5th metatarsal osteotomies. All the angles measured except for the DMAA showed a statistically significant reduction post-operatively

Introduction. Hallux valgus is a common orthopaedic complaint with multiple surgical options. There are many methods available for assessing whether sufficient translation of the first metatarsal can be achieved with a metatarsal translational osteotomy alone. None of the current methods take into account the breadth of the metatarsal. With current PACS technology a radiograph can be zoomed to any size and we postulate that by using the surgeon's thumb (or any suitable digit), as a sizing tool, a safe clinical decision can be made concerning whether a translational metatarsal osteotomy alone will provide sufficient correction. Method. We reviewed the preoperative radiographs (weightbearing AP) of twenty patients who had scarf and akin osteotomies and twenty patients with a deformity too great for scarf and akin osteotomies. The senior author (CC) taught the rule of thumb to one consultant and two registrars (total two registrars and two consultants). The radiographs were blindly randomised and the participants assessed each radiograph and decided whether sufficient translation could be achieved with a translational metatarsal osteotomy alone. The process was repeated three months later. Twenty patients were deemed sufficient for intra-user variability and significance based on a recent JBJS(A) article concerning radiographic measurements post proximal crescentic osteotomy (Shima et al. 2009). Results. Good inter- and intra- user variability was demonstrated and using the rule of thumb is a safe way of determining whether a distal osteotomy alone will provide sufficient correction

When performing scarf osteotomies some surgeons use intraoperative radiography and others do not. Our experience is that when using intraoperative radiography we often change the osteotomy position to improve the correction of the hallux valgus angle and sesamoid position. We report the results of a single surgeon series of 62 consecutive patients who underwent a scarf osteotomy for hallux valgus. The first 31 patients underwent surgery without the use of intraoperative radiographs and the subsequent 31 patients underwent surgery with the use of intraoperative radiographs, this reflects a change in the surgeons practice. Hallux valgus angle, intermetatarsal angle, distal metatarsal articular angle and sesamoid position using the Hardy Clapham grading system were recorded. All patients had measurements recorded from weight baring radiographs taken pre operatively as well as at 6 and 12 weeks post operatively. Intraoperative measurements were also recorded for all patients in the intraoperative radiography group. The mean hallux valgus angle preoperatively was 28.5° in the control group and 30.5° in the intraoperative radiography group. The mean hallux valgus angle in the control group at 6 weeks was 12.4° and at 12 weeks was 12.6°. The mean hallux valgus angle in the intraoperative radiography group at 6 weeks was 10.5° and at 12 weeks was 9.8°. The median sesamoid position pre operatively was 4 for both groups. At 6 and 12 weeks the sesamoid position improved by a median of 1 position in the control group and 2 positions in the intraoperative radiography group (p<0.05). We recommend that surgeons who do not routinely use intraoperative radiography undertake a trial of this. We have found that the use of intraoperative radiography improves the correction of hallux valgus angle and sesamoid position. These have been shown to increase patient satisfaction and reduce recurrence

We performed distal chevron osteotomy of the second, third, or fourth metatarsal for painful plantar callosities in 19 non-rheumatoid patients (16 women, 3 men; 21 feet); their mean age was 59 years (32 to 85). The mean follow-up was four years (2 to 7). The overall results were good in 16 feet, fair in two, and poor in three, with four patients still having painful plantar callosities. There was union in all feet, but transfer metatarsalgia developed in three and three required an orthosis. Distal chevron osteotomy for intractable plantar callosities was successful both clinically and radiologically in most patients

Introduction. The literature remains controversial on treatment of advanced stages of first metatarsophalangeal (MTP) arthritis and frequently favors arthrodesis. However, complications and suboptimal outcomes in active patients still remain with fusion of the first MTP joint. This study reports results of patients who underwent metallic resurfacing of the metatarsal side of the MTP joint. Materials and Methods. Twenty seven patients (31 implants) with stage II or III hallux rigidus underwent resurfacing with a fourth generation (screw fixation) contoured MTP implant and were willing to participate in a follow up study comparing pre- and postoperative radiographs, range of motion, AOFAS and SF-36 scores. The average age of these patients was 51 years (range 35-74) and the average follow up was 54 months (range 45-66). Results. The postoperative assessment demonstrated statistically significant improvements in range of motion, AOFAS, and SF-36 scores (P<0.05) when compared to baseline. The mean preoperative AOFAS scores improved from 51.5(range 35-74) to 94.1 (range 82-100). The mean preoperative active range of motion improved from 19.7 degrees (range 5-50) to 47.9 degrees (range 25-75). The mean preoperative passive range of motion improved from 28.0 degrees (range 10-60) to 66.3 degrees (range 40-90). The mean SF-36 score improved from 71.2 (range 60.6-80.0) to 88.2 (range 69.6-99.1), physical health sub scores improved from 66.8 (range 40-87) to 90.1 (range 70-98). The average time for return to work was 7 days (range 3-20). There was one implant revision due to phalangeal disease progression. All other patients were satisfied and willing to have the procedure performed again. Conclusion. Current 4 and 5 year results are very promising. Preservation of joint motion, alleviation of pain and functional improvement data are very encouraging. Because minimal joint resection is performed, conversion to arthrodesis or other salvage procedures is relatively simple if further intervention is necessary

Introduction

Arthroplasty for treatment of end stage hallux rigidus is controversial. Arthrodesis remains the gold-standard, but this procedure is not without complications, with up to 10% non-union, 14% re-operation and 10% transfer metatarsalgia rates reported.

The aim of this study was to analyse the outcome of the double-stemmed silastic implant (Wright-Medical) for end stage hallux rigidus.

Background

Patient reported outcome and experience measures have been a fundamental part of the NHS. We used PROMS2.0, a semi-automated web-based system, which allows collection and analysis of outcome data, to assess the patient reported outcome/experience measures for scarf+/− akin osteotomy for hallux valgus.

Aim. Forefoot ulcers in patients with diabetic neuropathy are a result of factors that result in increased forefoot plantar pressures. Progressive hindfoot equinus from contraction of gastrocnemius-soleus-tendo-Achilles complex and progressive plantar flexed metatarsal heads secondary to claw toe deformity results callus at the metatarsal heads which break down to ulceration. The aim is to describe 2-stage treatment pathway for managing these ulcers. Methods. Consecutive patients, who presented with forefoot ulcers since February 2019 were treated with a 2-stage treatment pathway. The first stage of this is an out-patient tendo-Achilles lengthening (TAL). The second stage is surgical proximal dorsal closing wedge metatarsal osteotomy for patients with persistent or recurrent ulcers. Patients were followed for a minimum of 12 months. Results. 112 patients (146 feet) underwent TAL by 3 consultants. Of these, 96 patients were followed for a minimum of 12 months (range 12–36 months). None had infection or wound related problems at the tenotomy sites; complete transection of the tendon was noted in 4 patients (4%) and one-patient developed heel callosity suggestive of over-lengthening. In 92 patients (96%), the ulcers healed within 10 weeks (± 4 weeks). Additional z-lengthening of peroneal longus and tibialis posterior tendons helped in patients with 1. st. metatarsal and 5. th. metatarsal head ulcers respectively. In 12 patients (10%), the ulcer failed to heal or recurred. MRI scan in these patients showed plantar flexed metatarsals from progressive claw toe deformity. The ulcer in this group healed after surgical offloading with proximal dorsal closing wedge osteotomy of the metatarsal/s, with no recurrence at a minimum 12months of follow-up. Conclusion. The described 2-stage treatment pathway results in long-term healing of neuropathic forefoot ulcers, and in 96% of patients, the ulcer healed after the first stage out-patient percutaneous TAL

Introduction. Treatment pathways of 5. th. metatarsal fractures are commonly directed based on fracture classification, with Jones types for example, requiring closer observation and possibly more aggressive management. Primary objective. To investigate the reliability of assessment of subtypes of 5. th. metatarsal fractures by different observers. Methods. Patients were identified from our prospectively collected database. We included all patient referred to our virtual fracture clinic with a suspected or confirmed 5. th. metatarsal fracture. Plain AP radiographs were reviewed by two observers, who were initially trained on the 5. th. metatarsal classification identification. Zones were defined as Zone 1.1, 1.2, 1.3, 2, 3, diaphyseal shaft (DS), distal metaphysis (DM) and head. An inter-observer reliability analysis using Cohen's Kappa coefficient was carried out, and degree of observer agreement described using Landis & Koch's description. All data was analysed using IBM SPSS v.27. Results. 878 patients were identified. The two observers had moderate agreement when identifying fractures in all zones, apart from metatarsal head fractures, which scored substantial agreement (K=.614). Zones 1.1 (K=.582), 2 (K=.536), 3 (K=.601) and DS (K=.544) all tended towards but did not achieve substantial agreement. Whilst DS fractures achieved moderate agreement, there was an apparent difficulty with distal DS, resulting in a lot of cross over with DM (DS 210 vs 109; DM 76 vs 161). Slight agreement with the next highest adjacent zone was found when injuries were thought to be in zones 1.2, 1.3 and 2 (K=0.17, 0.115 and 0.152 respectively). Conclusions. Reliability of sub-categorising 5. th. metatarsal fractures using standardised instructions conveys moderate to substantial agreement in most cases. If the region of the fracture is going to be used in an algorithm to guide a management plan and clinical follow up during a virtual clinic review, defining fractures of zones 1–3 needs careful consideration