Review of radiographic measurements following Austin bunionectomy

This study compared preoperative and postoperative results for selected radiographic measurements of 30 patients undergoing the modified Austin bunionectomy procedure for the correction of hallux abducto valgus. Significant reductions in all postoperative radiographic values were demonstrated, including hallux abductus angle, metatarsus primus adductus angle, tibial sesamoid position, and first metatarsal protrusion distance.     

Alternate method of reducing metatarsus primus adductus angle

Dr. Evins suggests a relatively simple technique to reduce the metatarsus primus adductus angle associated with hallux abducto valgus. It is used in conjunction with other bunionectomies--often with the modified McBride bunionectomy or the Reverdin osteotomy--with satisfactory results and often makes the Logroscino double osteotomy unnecessary.     

Roger A. Mann Award. Juvenile hallux valgus: etiology and treatment

In an 11-year retrospective study of 45 patients (60 feet) with juvenile hallux valgus, a multiprocedural approach was used to surgically correct the deformity. A Chevron osteotomy or McBride procedure was used for mild deformities, a distal soft tissue procedure with proximal first metatarsal osteotomy was used for moderate and severe deformities with MTP subluxation, and a double osteotomy (extra-articular correction) was used for moderate and severe deformities with an increased distal metatarsal articular angle (DMAA). The average hallux valgus correction was 17.2 degrees and the average correction of the 1-2 intermetatarsal angle was 5.3 degrees. Good and excellent results were obtained in 92% of cases using a multiprocedural approach. Eighty-eight percent of patients were female and 40% of deformities occurred at age 10 or younger. Early onset was characterized by increased deformity and an increased DMAA. Maternal transmission was noted in 72% of patients. An increased distal metatarsal articular angle was noted in 48% of cases. With subluxation of the first MTP joint, the average DMAA was 7.9 degrees. With a congruent joint, the average DMAA was 15.3 degrees. In patients where hallux valgus occurred at age 10 or younger, the DMAA was increased. First metatarsal length was compared with second metatarsal length. While the incidence of a long first metatarsal was similar to that in the normal population (30%), the DMAA was 15.8 degrees for a long first metatarsal and 6.0 degrees for a short first metatarsal. An increased DMAA may be the defining characteristic of juvenile hallux valgus. The success of surgical correction of a juvenile hallux valgus deformity is intimately associated with the magnitude of the DMAA. Moderate and severe pes planus occurred in 17% of cases, which was no different than the incidence in the normal population. No recurrences occurred in the presence of pes planus. Pes planus was not thought to have an affect on occurrence or recurrence of deformity. Moderate and severe metatarsus adductus was noted in 22% of cases, a rate much higher than that in the normal population. The presence of metatarsus adductus did not affect the preoperative hallux valgus angle or the average surgical correction of the hallux valgus angle. Constricting footwear was noted by only 24% of patients as playing a role in the development of juvenile hallux valgus. There were six recurrences of the deformities and eight complications (six cases of postoperative hallux varus, one case of wire breakage, and one case of undercorrection).     

Role of medical capsule and transverse metatarsal ligament in hallux valgus deformity

The role of the medial capsule and transverse metatarsal ligament in hallux valgus deformity including stability of the first metatarsophalangeal and adjacent joints was investigated in vitro. The three-dimensional positions of the proximal phalanx, first metatarsal, and second metatarsal before and after sectioning the medial capsule and metatarsal ligament were measured using a magnetic tracking system. Valgus deformity of the hallux increased with medial capsule sectioning an average of 22.3 degrees +/- 6 degrees. Valgus deformity of the hallux increased with medial capsule and metatarsal ligament sectioning an average of 27.4 degrees +/- 9.1 degrees. Valgus deformity of the hallux did not change significantly after sectioning the metatarsal ligament only. No significant changes were found in varus and eversion of the first metatarsal, in valgus of the second metatarsal, in the distance between first and second metatarsal heads after sectioning the medial capsule, or in the metatarsal ligament. This study shows the importance of the medial capsule in hallux valgus deformity. The transverse ligament did not contribute substantially to cause the deformity.     

Hallux valgus due to cuneiform-metatarsal instability

We present a biomechanical rationale for the treatment of severe hallux valgus deformity by realignment and arthrodesis of the first cuneiform metatarsal (CM) joint. We think that this severe hallux valgus deformity represents instability at the CM-1 articulation, since normal motion at that joint is very small. A forefoot compression test was used to assess the foot preoperatively. This was found not only to realign the first metatarsal, but also to align the metatarsophalangeal joint. A surgical procedure has evolved to include a transverse screw between the first and second metatarsal bases, as well as a second screw from first cuneiform to first metatarsal base, along with a small-volume bone graft of the CM-1 articulation. This is a modern variant of the Lapidus procedure.     

Gastrointestinal drugs

The cutaneous glands of the forehead and the metatarsus were studied by histological and histochemical methods and electron microscopy in adult male and female impalas in various seasons of the year. All glandular areas consist of apocrine and holocrine glands, which, however, occur in different proportions. Our findings in the apocrine gland cells suggest (1) the synthesis and exocytosis of a glycoproteinaceous secretory product stored in secretory granules, (2) typical apocrine secretion of the transformed apical cytoplasm, and (3) transepithelial fluid transport. The Golgi apparatus and apical membrane have binding sites for several lectins (PNA, HPA, RCA I, WGA). Cytokeratins 7, 14 and 19 are expressed at various intracellular localizations, suggesting an active role in the secretory mechanisms. The glands of the male forehead show marked seasonal changes in activity that are correlated with the main phases of the reproductive cycle, with the highest cellular activity occurring during the rut in April/May. The female forehead glands are only moderately developed and do not undergo seasonal changes. The metatarsal glands are of equal size in males and females and show no seasonal changes in activity. This study supports the hypothesis that (1) forehead glands in the male have a signaling role in the rut and (2) the metatarsal glands have a more general, probably social role maintaining and restoring contact between herd members.     

The demography of limb dominance, body-mass index, and metatarsus adductus deformity

To test the null hypothesis that limb dominance (laterality) and side of complaint are not associated in a diverse population, nearly 400 patients (40% male, 60% female) of varying age and body size from three South Florida podiatric medical teaching facilities were surveyed in 1995-1996. Radiographs of feet were available for 15% of the patients, and the metatarsus adductus angle was measured on each x-ray. The typical patient was a women (median age, 49 years) of average body weight and average body-mass index. No statistical association was found between laterality and side of complaint in the broader sample, although a significant association did appear in the subsample of patients with bilateral x-rays. The prevalence of metatarsus adductus deformity (metatarsus adductus angle > 15 degrees) among patients with x-rays was 62%. No sex-specific, age-specific, or body size-specific associations were found between handedness and metatarsus adductus deformity.     

Measuring first ray mobility with a new device

First ray hypermobility has been linked to many abnormal conditions in the foot. First metatarsal vertical displacement is proportional to the measurement of first ray dorsiflexion. A new device that measures first ray mobility has been built and tested. The device applies a dorsiflexing force to the head of the first metatarsal and measures the amount of vertical displacement that results. The design and instrumentation of the device is described. A safe and reliable testing procedure for measuring maximal first ray displacement is discussed. Clinicians could use this measure when selecting treatment options for patients who suffer foot pathologies resulting from faulty mechanics of the first ray.     

Functional analysis of linker insertions and point mutations in the alpha-Amy2/54 GA-regulated promoter

First metatarsal fractures are rare because of their thick size and shape. They are to be treated aggressively because of the prolonged disability associated with such fractures. Any injury to the first ray may drastically alter the pattern of normal gait and weight-bearing. Most of the literature regarding such fractures is anecdotal, and there is little in the way of scientific articles that investigate their management. The general consensus for treatment of closed, nondisplaced first metatarsal fractures is to use some form of plaster immobilization. Nevertheless, there is much variation in the literature concerning the length of time patients should be casted. Rigid internal fixation using AO techniques is preferred if open reduction is to be instituted. Long-term complications with first metatarsal fractures are attributed mostly to malunion in the sagittal plane, resulting in a nonplantigrade foot.     

Measurement of dorsal mobility in the first ray: elimination of fat pad compression as a variable

Previous designs for a device to measure first ray mobility have included compression of the first metatarsal fat pad as part of the measurement of displacement or have failed to standardize the force applied to the head of the first metatarsal. In this investigation, assessment of vertical mobility of the first ray of both feet in 14 volunteers was determined using a device that applied dorsiflexing force to the first metatarsal. First ray displacement was measured initially from the plantar surface and then from the dorsal aspect of the head of the first metatarsal. The difference between plantar- and dorsal-surface-measured vertical displacement was highly significant. This study suggests that mobility of the first ray measured from the dorsal aspect of the first metatarsal head eliminated compression of the plantar fat pad from being interpreted as part of the measurement of displacement.     

The painful foot, Part I: Common forefoot deformities

The incidence of forefoot pain and deformity increases with age. Metatarsal stress fracture may be diagnosed by palpating each metatarsal head. Clinical diagnosis of interdigital neuroma is made by applying top-to-bottom pressure to the suspected interspace with one hand while applying side-to-side pressure across the forefoot with the other hand. Clinical examination of patients with bunion reveals pain on palpation of the erythematous prominent metatarsal head. Features of hallux limitus include pain or crepitus and decreased motion of the first metatarsophalangeal joint. Hammer digit syndrome may be caused by excessive pronation, supination, neuromuscular deformities or systemic disease. Pain that occurs beneath the sesamoid apparatus with weight bearing or palpation may indicate sesamoiditis. With early diagnosis, conservative therapy is often successful in the treatment of common disorders of the forefoot.     

Juvenile hallux abducto valgus association with metatarsus adductus

The authors evaluated the radiographs of 40 patients (72 feet) under 21 years of age who underwent surgery for symptomatic hallux abducto valgus deformity at Northlake Regional Medical Center. Forty-eight of 72 feet had metatarsus adductus angles greater than 15 degrees. A statistically significant correlation was found between an increasing metatarsus adductus angle and an increasing hallux abductus angle.     

Aberrant FHIT transcripts in cancerous and corresponding non-cancerous lesions of the digestive tract

We lengthened seven first metatarsals in four patients with short great toes by callus distraction using an external fixator. Good clinical and cosmetic results were obtained. Bone lengthening is effective in patients with short great toes not only for cosmesis, but also to relieve pain and callosities on the plantar aspect of the second and third metatarsal heads. Excessive lengthening of the first metatarsal resulted in limitation of the range of movement of the metatarsophalangeal joint of the great toe. To prevent this the amount of lengthening should not exceed 40% of the preoperative length of the metatarsal.     

Increase in magnesium plasma level after orally administered trimagnesium dicitrate

The distal metatarsal osteotomy according to Magerl allows correction of a hallux valgus deformity by lateral and plantar displacement as well as by pronation and variasation. The length of the first metatarsal can be adjusted by the depth of the cut at the resection or by a slightly oblique osteotomy. If necessary, soft tissue release and/or a osteotomy of the first proximal phalanx can be done to relocate the sesamoids under the head of the first metatarsal. A review of 118 foot operations in 75 patients demonstrated a very good or good result in about 75%. Radiological examination showed sufficient lateralisation of the metatarsal head. Evaluating the length of the first metatarsal and the amount of variation, the results were less satisfying. The metatarsophalangeal angles could be corrected by 14 degrees and the intermetatarsal angles by 7 degrees on average. The sophisticated operative procedure limits the use of this technique as a standard procedure.     

Jones' fractures and related fractures of the proximal fifth metatarsal

At least three fracture types occur in the proximal fifth metatarsal: the Jones' fracture, the proximal diaphysial stress fracture, and the tuberosity avulsion fracture. Each has distinct characteristics. The diaphysial stress fracture is commonly confused with the Jones' fracture, thereby obscuring vital differences in prognosis and treatment. Anatomical and biomechanical characteristics, as well as vascular studies of the proximal portion of the fifth metatarsal, are discussed in an attempt to better understand their diverse healing potentials. Guidelines for treatment are controversial, and must frequently be individualized. Although surgical intervention for certain proximal fifth metatarsal fracture types may speed recovery time, most fractures heal with immobilization. Treatment of displaced, intra-articular fractures, delayed unions, and nonunions usually requires operative methods.     

Metatarsus varus corrected by open wedge osteotomy of the first cuneiform bone

The persistence of metatarsus adductus varus has been a problem in management. We have treated a series of selected patients with this problem and believe that our results have been better than with the procedure we have used in the past. Fowler has described a procedure which seems ideal for the patients in our series. Through personal communication the procedure and its application were discussed and the series was started eight years ago. Our series is small because our patients are responding to other forms of treatment at an earlier age. The few that do not respond are now considered for the operation described. The procedure is relatively simple to perform. Full correction should be obtained at the time of surgery. Casting is utilized to hold the correction and immobilize the extremity for healing. Our unsatisfactory results occurred because of errors in technique or poor selection of patients. We believe that this procedure should be considered in the older patient with metatarsus varus.     

Substrate specificity of ascidian sperm trypsin-like proteases, spermosin and acrosin

We retrospectively reviewed the office records of the senior author--which include two national ballet companies--and identified 35 dancers who sustained distal shaft fractures of the fifth metatarsal. The usual fracture pattern is a spiral, oblique fracture starting distal-lateral and running proximal-medial. Treatment consisted of open reduction and internal fixation for 2 patients, closed reduction and percutaneus fixation for 2 patients, short leg weightbearing cast for 7 patients, and an elastic wrap and treatment of symptoms for 24 patients. Patients with marked displacement of the fracture underwent internal fixation early in the study period; but more recent treatment emphasized nonoperative means, even for displaced fractures. The average time to pain free walking was 6.1 weeks (range, 0 to 16); return to barre exercises, 11.6 weeks (range, 4 to 48); and return to performance, 19 weeks (range, 6 to 52). There was one delayed union (7 months) and one refracture (2 months) that subsequently healed. All patients returned to professional performance without limitation and no patient reported pain with performance at followup. Spiral fractures of the distal shaft of the fifth metatarsal are common injuries and can usually be treated nonoperatively for these high performance athletes without long-term functional sequelae.     

Running shoes for relief of plantar pressure in diabetic patients

There is a causal relationship between diabetic foot ulceration, elevated plantar pressure, and severe sensory neuropathy. Cushioned footwear intended to relieve plantar pressure is well established for prevention and healing of plantar ulcers. The aim of the present study was to investigate whether pressure relief by means of a running shoe with optimized forefoot pressure damping is comparable to that of a custom-made soft insole placed into an in-depth shoe. The in-shoe pressures were compared to an in-depth shoe with the original cork insole and with a leather-soled Oxford shoe. The maximum reduction of plantar pressure in the running shoe was 47% under the 2nd and 3rd metatarsal heads, 29% at the first metatarsal head, and 32% at the great toe in comparison to the Oxford shoe. This was surpassed only by the custom-made insole, which reduced pressures at the metatarsal heads by 50%. The specially designed running shoe yielded the same pressure relief at the central metatarsal heads as the custom-made insole. Such shoes are likely to be very useful in preventing diabetic foot ulceration in high-risk patients as a comparatively affordable and immediately available device.     

Metatarsus proximus and digital divergence. Association with intermetatarsal neuromas

A retrospective radiologic study was performed to determine whether there is an increased finding of metatarsus proximus and digital divergence in patients with a confirmed diagnosis of intermetatarsal neuroma when compared with an asymptomatic group. The study included 48 patients with pathologic confirmation of neuroma and 100 asymptomatic patients. Results of the study revealed no statistical relationship between the radiologic findings of metatarsus proximus and digital divergence and the physical occurrence of neuromas. An unexpected finding was an increased intermetatarsal angle of the affected interspace in the neuroma group.     

Surgical treatment of mal perforans

Mal perforans is a chronic foot ulcer commonly found in diabetics with neuropathy. Although it will often respond to conservative measures, recurrence is frequent and brings with it the risk of spreading infection and serious destruction of tissues. Surgical treatment of seven patients, based on excision of the distal metatarsal bone (five patients), or excision of the distal metatarsal and amputation of the first toe (two patients), gave satisfactory results and is indicated to achieve long-term healing. A special shoe, designed to remove pressure from the healing areas as well as from potential new pressure points, was used in the last four patients.