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As a surgical treatment of metatarsus primus varus in the adult, metatarsal osteotomy toward valgus near the base with internal fixation using a 40-mm AO small-fragment cancellous screw, in which a medical cortical console has a stabilizing function for the support of the screw head, has proved successful in 31 cases.
Metatarsus adductus deformity should be recognized and addressed appropriately and in a timely fashion so as to achieve an effective correction with low rates of recurrence. Early diagnosis and treatment are of paramount importance, because spontaneous resolution is rare. Although nonoperative treatment is desirable via manipulation and soft tissue stretching and serial cast immobilization, appropriate surgical intervention needs to be used on occasion to achieve correction of resistant cases. Depending on the severity and flexibility of the deformity and the age of the patient, various methods of surgical reconstruction are available. A long-standing untreated or undertreated adductus deformity can lead to the formation of a skewfoot deformity with more significant symptoms and deformity. Treatment of this deformity is rarely successful by nonoperative means, and appropriate surgical procedures addressing the metatarsal adductus component and the flatfoot component can be used for correction of the dysfunctional or symptomatic skewfoot.
The crescentic basilar first metatarsal osteotomy has been largely abandoned by the podiatric community in recent years in favor of proximal wedge-type osteotomies for the correction of metatarsus primus varus with large intermetatarsal angles. In most cases, this was due to the inherent instability of the osteotomy and difficulties with fixation. However, the crescentic osteotomy has the ability to correct in all three planes with less shortening than the wedge-type osteotomies. New fixation techniques, such as the small cannulated screw systems, have allowed for less technical difficulty in obtaining rigid internal fixation. In this article, the authors describe the results in 29 feet (27 patients) where the crescentic osteotomy was performed along with a metatarsaphalangeal joint procedure ranging from a McBride (with or without lateral sesamoidectomy) to a phalangeal osteotomy. Preoperative intermetatarsal angles ranged from 11 degrees to 22 degrees, with an average of 18.6 degrees. Postoperative intermetatarsal angles ranged from 2.6 degrees to 8.2 degrees with an average of 5.1 degrees. The preoperative hallux abductovalgus angles ranged from 25 degrees to 38 degrees, with an average of 33.6 degrees. The postoperative hallux abductovalgus angles ranged from 4 degrees to 18 degrees with an average of 11 degrees. Complications included one hallux varus, one delayed union, and three cases of superficial cellulitis that resolved with oral antibiotic therapy.
This report describes the case of a 15-month-old alpaca stallion with an open fracture of metatarsus (MT) III/IV that occurred during transportation. Despite of a guarded prognosis, the animal was operated on request of the owner. The surgical intervention consisted of meticulous lavage and curettage of the wound and affected bone, precise fracture reduction, internal fixation with a 12-hole broad 3.5 mm DCP and implantation of a gentamicin impregnated collagen sponge. Primary wound healing was evident and the implant was removed at 3 months after the initial intervention. At 14 months after surgery, the stallion did not show any signs of lameness and was used for service.
The purpose of this study was to determine the incidence of the intermetatarsal facet on the lateral aspect of the base of the first metatarsal and its role in the medial angulation of the proximal metatarsal base as it relates to metatarsus primus varus. A total of 77 human first metatarsals were examined for the presence of the intermetatarsal facet. The intermetatarsal facet was seen on the lateral aspect of the first metatarsal base, superior to the tuberous attachment of the peroneus longus tendon. The obliquity of the first metatarsal base was measured on metatarsals with and without the intermetatarsal facet. The intermetatarsal facet was present on 22 of 77 first metatarsals, or 29% of specimens. The proximal obliquity angle was 2.92 degrees in metatarsals without the facet and 4.63 degrees when the facet was present. This increase in the medial obliquity of the proximal first metatarsal base in the presence of an intermetatarsal facet was statistically significant (P < .002). The intermetatarsal facet between the first and second metatarsals may have a role in an increased medial obliquity of the first metatarsal base and is present in approximately 30% of the population.
At the University of Vienna Department of Orthopaedics, 26 feet in 21 patients were treated with a basal osteotomy for hallux valgus associated with metatarsus primus varus. In 85% of the cases, a satisfactory result was achieved. Critical analysis revealed shortening of the first metatarsal and elevation of its head, which resulted in excess lateral straining of the foot and metatarsalgia. In 15 cases, osteoarthritis in the metatarsocuneiform joint was also increased. Given these results, an osteotomy that prevents shortening of the first metatarsal and elevation of the head of the first metatarsal, or one that takes these facts into account, seems ideal.
Proximal crescentic metatarsal osteotomy is a clinically successful technique for correcting metatarsus primus varus in hallux valgus surgery. However, there have been instances of dorsal elevation of the metatarsal head with this technique. Mechanical testing on 10 matched pairs of cadaver feet was performed to evaluate a new technique combining a biplanar closing wedge osteotomy and plantar plate fixation versus crescentic metatarsal osteotomy. The specimens were tested in cantilever-bending mode on an MTS Mini Bionix test frame. The mean load-to-failure values were 127.2 +/- 81.9 N (SD) for biplanar osteotomy with plate fixation and 44.9 +/- 43.3 N for crescentic osteotomy (P = 0.019); the mean stiffness values at the initial portion of the load-deflection curve were 83.11 +/- 73.76 N/mm and 31.95 +/- 43.00 N/mm, respectively (P = 0.012). The biplanar wedge osteotomy with plantar plate fixation demonstrated significantly stronger fixation than the crescentic osteotomy, with higher mean load-to-failure and stiffness values. This newly described technique may provide an acceptable alternative for patients at risk for dorsal elevation of the metatarsal, particularly those who are noncompliant or have osteopenia. Clinical study will determine whether this new technique offers satisfactory long-term results.
Between 1974 and 1985, 59 patients (83 feet) underwent basal closing wedge osteotomy in combination with a bunionectomy and a lateral soft tissue release for correction of hallux valgus and metatarsus primus varus at this institution. Of the original 59 patients, 42 patients (60 feet) with at least 10 years of follow-up (average, 194 months; range, 144-266 months) were available for this study. Results were analyzed by review of the medical records and plain radiographs, a standardized clinical questionnaire, and physical examination. Of the 60 feet, patients rated outcomes as excellent or good in 51 feet (85%) and rated cosmesis as excellent or good in 44 feet (73%). Radiographically at final follow-up, hallux valgus and intermetatarsal angles averaged 19.9 degrees (range, 0-40 degrees) and 6.7 degrees (range, 0-18 degrees), respectively. The sesamoid position was corrected from an average preoperative grade of 2.6 to a grade of 0.9 at final follow-up. The average shortening of the first metatarsal was 5 mm. The disadvantages of the closing wedge osteotomy are that it is technically demanding and it entails the risk of shortening, dorsal malalignment, and metatarsalgia. In the current study, long-term complications included hallux varus deformity (16 feet), dorsal malalignment (15 feet), and metatarsalgia (14 feet). Despite good correction of the intermetatarsal angle and sesamoid position, the clinical results and the incidence of complications after basal closing wedge osteotomy were not as favorable as those reported for other procedures in the literature. Therefore, alternative procedures, such as the basal crescentic osteotomy or the basal chevron osteotomy, should be used.
Two hundred seventy-five lateral weightbearing radiographs of isolated pathology were reviewed and stratified into hallux rigidus (n = 100), hallux valgus (n = 75), plantar fasciitis (n = 50), and Morton's neuroma (n = 50) groups. The patient population consisted of healthy individuals with no history of foot trauma or surgery. The first to second metatarsal head elevation, Seiberg index, first to second sagittal intermetatarsal angle, first to fifth metatarsal head distance, and hallux equinus angle were measured in each population. Statistically significant differences were found between the hallux valgus, plantar fasciitis, and Morton's neuroma populations and the hallux rigidus population, which showed greater elevation of the first metatarsal relative to the second for each radiographic measurement technique. In the hallux rigidus population, there was a statistically significant difference between grade II and grades I and III regarding the first to fifth metatarsal head distance (greater in grade II) and the hallux equinus angle (lower in grade II). A review of the literature and comparison with historical controls reveals that metatarsus primus elevatus exists in hallux rigidus and is greater than that found in hallux valgus, plantar fasciitis, and Morton's neuroma groups.
Hallux abducto valgus with concomitant metatarsus primus adductus was treated by either an isolated Austin bunionectomy or by a combination of a modified McBride bunionectomy, along with a closing base wedge osteotomy, on a total of 73 patients (88 feet) from 1983 to 1993. Both subjective and objective similarities and differences were compared between these two groups of patients. Long-term elevation or depression of the first ray was analyzed by using a technique termed sagittal plane displacement. The prevalent preoperative symptoms were significantly reduced postoperatively in both groups of patients. Initial postoperative elevation of the first ray occurred in approximately one third of the cases in both groups. Long-term elevation of the first ray was greater with the base wedge osteotomy and did not change appreciably with the Austin procedure. The sagittal plane displacement method is a helpful tool in analyzing changes in the position of the first ray perioperatively.
The authors investigated the effect of x-ray tube head angulation and central ray direction on the position of the first metatarsal relative to the second metatarsal in the lateral foot radiographic view. This preliminary study shows that these variables may influence the perception of metatarsus primus elevatus in the weightbearing lateral foot radiograph.
The closing subtraction osteotomy of the first cuneiform effectively reduces pronounced obliquity of the first metatarsal cuneiform joint and predictably reduces the intermetatarsal angle in patients with metatarsus primus adductus. This osteotomy is combined with other procedures in surgical realignment of the first ray. Cases best suited for this procedure must be selected carefully. The procedure involves resecting the existing bone block from the opposing surfaces of the first and second metatarsal bases and from the distal one half of the opposing surfaces of the first and second cuneiforms. A triangular-shaped wedge of bone is then resected from the midbody of the first cuneiform while retaining a medial hinge. Closure of the first cuneiform osteotomy should require only minimal pressure. Two threaded Steinman pins transfix the osteotomy site. The vascular cancellous bone of the first cuneiform assures adequate healing of the osteotomy site.
Multiple toes may develop on the medial or lateral side of the forefoot or in its middle. This may involve duplication of only the distal phalanx or the whole hallux including the metatarsal. In a duplicated big toe, the phalanx to be maintained, because short muscles of the leg are attached to it, is usually localized medially. A rare case of dysplasia of the first metatarsus, following a resection indicated in childhood for a hallux triples, is described in a 20-year-old girl. In order to remove hallux insufficiency and an overloading of the middle metatarsals, the authors decided to carry out a one-stage prolongation of the first metatarsal, using an autologous tricorticcal graft collected from the pelvis and a dynamic compression plate. No surgical treatment of the middle metatarsals was indicated because a disproportionate, short foot would result. Both the subjective and objective status of the patient at 6 months after the operation showed that the non-standard prolongation procedure was correctly indicated and allowed for physiological loading of the foot and restoration of normal walking.
(1) Bone biopsies from the femoral heads and the fourth metatarsal head were obtained in the patients with idiopathic necrosis of the femoral head and with rheumatoid arthritis. (2) 71.4% of the patient with idiopathic necrosis of the femoral head revealed fatty degeneration of osteocytes in either the femur and/or metatarsus. (3) 57% of those patients demonstrated hyperlipidemia. (4) Metatarsal biopsies obtained from the patients with rheumatoid arthritis disclosed no fatty degeneration of osteocytes except in one patient treated with steroids.
The authors report on "congenital primitive metatarsus varus". After discussing the incidence, etiology, pathogenesis and classification, the clinical features and associated malformations are evaluated. Then they go into treatment details affirming, according to the literature, that this malformation is susceptible to complete regression if treated bloodlessly during the early months of life, and in any case, before the onset of loss of ambulation, by manipulations followed by a series of plaster casts and finally by corrective braces and shoes. If this treatment is fruitless or in cases seen at an advanced age and with a high degree of varus, there are several surgical operations that achieve satisfying results operating on tendons or on articular capsules.
Congenital metatarsus adductus, a deformity at the tarsometatarsal joints in which the metatarsals are deviated internally in relation to transverse plane, predisposes to "pigeon-toed" gait. Treatment is aimed at achieving normally balanced foot by overcorrection at the deformity sites. The most common problem after treatment is pronation deformity, which can be avoided by carefully positioning the heel at the time of casting. The sooner conservative measures are instituted, the more easily and rapidly the deformity will be corrected. If conservative casting does not result in improvement, then soft tissue surgery is indicated.
A trigonometric evaluation of the amount of correction of metatarsus primus varus obtainable via lateral displacement of the first metatarsal head in a Chevron osteotomy technique revealed that approximately 1 degree of correction may be obtained for each millimeter of lateral shift. This calculated correction was correlated with the actual correction obtained in ten feet. Narrowing of the metatarsal head associated with removal of the medial eminence was an additional corrective factor.
A retrospective study of two aspects of the Evans calcaneal osteotomy with bone graft is presented. First, the postoperative casting time can be decreased significantly to 3 weeks of nonweightbearing and 3 weeks of weightbearing. Second, the metatarsus adductus angle remains relatively unaltered after the procedure.