Ilizarov metatarsal bone lengthening in treatment of diabetic foot ulcer complicated with chronic osteomyelitis of metatarsal head / 中国修复重建外科杂志

Objective: To explore the effectiveness of the first-stage debridement and Ilizarov metatarsal bone lengthening in treatment of diabetic foot ulcer complicated with chronic osteomyelitis of metatarsal head. Methods: Between January 2015 and October 2018, 8 cases (9 feet, 11 sites) of diabetic foot ulcer complicated with chronic osteomyelitis of metatarsal head were treated by first-stage debridement and Ilizarov metatarsal bone lengthening. There were 3 males (4 feet, 5 sites) and 5 females (5 feet, 6 sites), with an average age of 57.5 years (range, 44-65 years). According to diabetic foot Wagner grade, 6 cases (7 feet) were grade 3 and 2 cases (2 feet) were grade 4. The chronic osteomyelitis located at left foot in 4 cases, right foot in 3 cases, and bilateral feet in 1 case. The duration of chronic osteomyelitis was 1-5 years (mean, 3.1 years). The chronic osteomyelitis site was the 1st metatarsal head in 3 feet, the 3rd metatarsal head in 1 foot, the 4th metatarsal head in 1 foot, and the 5th metatarsal head in 6 feet. Two patients had chronic osteomyelitis at 2 sites on 1 foot. The length of lengthened metatarsal bone, lengthening time, and the time of wearing external fixation frame were recorded, and the external fixation frame index was calculated. The healing conditions of foot ulcer and lengthening bone segment were observed, the healing time was recorded, and the healing index of lengthening bone was calculated. The ankle function was evaluated according to the American Orthopedic Foot and Ankle Society (AOFAS) score criteria. Results: All patients were followed up 9-26 months with an average of 15.0 months. Except pin tract infection during the bone lengthening period, there was no complications such as skin necrosis and vascular or nerve injury occurred during treatment. The length of lengthened metatarsal bone was 12-35 mm with an average of 20.5 mm; the metatarsal bone lengthening time were 21-84 days with an average of 57.8 days. The average time of wearing external fixation frame was 14.6 weeks (range, 10.4-21.1 weeks) and the external fixation frame index was 54.3 days/cm (range, 42.9-59.2 days/cm). The ulcer wound healed with an average healing time of 30.5 days (range, 19-70 days) and no ulcer recurrence was observed during follow-up. Bone healing was obtained in all bone lengthening segments, and the average healing index was 42.5 days/cm (range, 37-51 days/cm). The average AOFAS score was 91.7 (range, 87-95); 5 feet were excellent and 4 feet were good. The excellent and good rate was 100%. Conclusion: The metatarsal bone lengthening under Ilizarov law of tension-stress after debridement can promote diabetic foot ulcers healing and reconstructing the length of metatarsal to retain the function of metatarsal load and avoid amputation. This is an effective method for the treatment of diabetic foot ulcer complicated with chronic osteomyelitis of metatarsal head.

Results of Dorsal Closing Wedge Osteotomy in Freiberg’s Disease

Introduction: Freiberg’s disease, the osteochondrosis of themetatarsal seen in our part of the world, usually at late stages,are refractory to the conservative treatment. Objective:Thepurpose of this study was to evaluate the results of dorsalclosing wedge osteotomy and pin fixation besides debridementand synovectomy.Material and Methods: Twenty patients (14 females,6 Males), mean age 19.3 years; range 14 to 26 years wereevaluated and teated by dorsal closing wedge osteotomy andpin fixation besides debridement and synovectomy, betweenseptember 2016 to 2018 at our institution. The presentingsymptoms were pain on walking or sports, limitation of dailyroutine activities, footwear problems, cosmetic deformitiesof forefoot and failed conservative treatment. Three patientshad a history of trauma. According to Smillies’s classificationtwelve patients were type IV and eight were Type V.Meanfollow-up period was 14.85 months(range 6 months to 24months).Results: Patients were assessed by the lessermetatarsophalangeal interphalangeal (LMPI) scale bykitaokaetal. At the final follow-up, scoring had changed from(44-66) with an average 54.65 to (76-100) with an average85.3. There was no case of infection, avascular necrosis,arthritis or pseudoarthrosis.Conclusion: Treatment of freiberg's disease with dorsalclosing-wedge osteotomy shows satisfactory pain relief andimprovement in quality of life

5th MTP Joint Reconstruction with Autogenic Costal Osteochondral Graft / 대한족부족관절학회지

The treatment of open, traumatic intraarticular injuries to the metatarsophalangeal joint with severe articular comminution and cartilage defect of metatarsal head is a challenge to the foot surgeon. We report the joint reconstruction treating the injured joint by autogenic costal osteochondral graft with satisfactory outcome.

Hallux Valgus and Cartilage Erosion in First Metatarsal Head: Correlation between Intraoperative Cartilage Erosion and Preoperative Parameters / 대한족부족관절학회지

PURPOSE: To analyze relation between age or parameters measured before operation and cartilage erosion of the first metatarsal head measured during operation. MATERIALS AND METHODS: The study was targeted at 56 patients and 79 feet, who underwent Scarf osteotomy or Scarf and Akin osteotomy from November 2009 through November 2010, and whose cartilage lesion of the first metatarsal head referred to the cartilage grade III or IV of the International Cartilage Repair Society. The measurement parameters were age, hallux valgus angle, intermetatarsal angle (1~2), tibial sesamoid position, proximal articular set angle and distal articular set angle. The cartilage erosion of the first metatarsal head was measured by one surgeon using cellophane. Occupancy rate and frequent involved sites of the cartilage erosion were recorded using AutoCAD(R) and adobe Illustrator CS4 program. SPSS correlation test and T-test were used for statistical analysis of the parameters and the cartilage erosion. RESULTS: The cartilage erosion was incurred frequently in the sagittal groove and the site where subluxation or dislocation of the tibial sesamoild bone occurred but frequent involved sites had no statistical significance with cartilage erosion. The age showed a statistical significance with the cartilage erosion in the correlation test (p=0.003). Especially, the group of over 51 year old patients was turned out to have association with the cartilage erosion, compared to the group of below 51 (p=0.007). But, hallux valgus angle, intermetatarsal angle (1~2), tibial sesamoid position, proximal articular set angle and distal articular set angle were no statistical significance with the cartilage erosion. CONCLUSION: We found the more the age of patients increased (especially above 51), the more cartilage erosion increased. And it is thought that we pay attention to reduce tibial sesamoid bone.

Surgical Treatment for Plantar Keratosis Using Vertical Chevron Osteotomy / 대한족부족관절학회지

PURPOSE: Painful plantar callosities under the second, third or fourth metatarsal head have been controverted about its treatment mordalities. We performed the vertical chevron osteotomy in patients with painful callosities on the second and third metatarsal head, and evaluated the outcome clinically. MATERIALS AND METHODS: Fourteen cases from 10 patients who had plantar keratosis were operated by vertical chevron osteotomy from March 2005 to October 2008. We used K-wire fixation for all cases. We evaluated the clinical results by the patients' satisfaction and disappearance of plantar lesion. RESULTS: The plantar keratosis was completely disappeared in 8 cases and partially in 5 cases. In 2 cases, patients expresses their pain caused by constant metatarsalgia that was suspected to be dorsal incisional pain and joint capsulitis. Transmetatarsalgia was not appeared. CONCLUSION: We consider vertical chevron osteotomy as a good surgical method for treatment of plantar keratosis.

Surgical Treatment for Plantar Keratosis Using Vertical Chevron Osteotomy / 대한족부족관절학회지

PURPOSE: Painful plantar callosities under the second, third or fourth metatarsal head have been controverted about its treatment mordalities. We performed the vertical chevron osteotomy in patients with painful callosities on the second and third metatarsal head, and evaluated the outcome clinically. MATERIALS AND METHODS: Fourteen cases from 10 patients who had plantar keratosis were operated by vertical chevron osteotomy from March 2005 to October 2008. We used K-wire fixation for all cases. We evaluated the clinical results by the patients' satisfaction and disappearance of plantar lesion. RESULTS: The plantar keratosis was completely disappeared in 8 cases and partially in 5 cases. In 2 cases, patients expresses their pain caused by constant metatarsalgia that was suspected to be dorsal incisional pain and joint capsulitis. Transmetatarsalgia was not appeared. CONCLUSION: We consider vertical chevron osteotomy as a good surgical method for treatment of plantar keratosis.

Closed Reduction and Fixation of Metatarsal Head and Neck Fractures Using Antegrade Intramedullary K-wire (6 Cases Report) / 대한족부족관절학회지

Metatarsal head and neck fractures are injuries that often result from a direct blow of a heavy objects to the metatarsal head. The head is often impacted or displaced to the plantar aspect that if not treated may cause malunion which later induces painful plantar calluses. If the fracture fragment is large enough, closed reduction may be successfully performed, but when the fragment is small or closed reduction is unsuccessful, open reduction is needed. We present our reduction and fixation technique for the metatarsal head and neck fractures using antegrade intramedullary Kirschner wire (K-wire) without opening the fracture site or infringing the metatarsophalangeal (MTP) joint which allows immediate motion of the joint and partial weight bearing in a stiff soled shoe.

Autogenous Osteochondral Graft for Freiberg's Disease: A Case Report / 대한족부족관절학회지

Freiberg disease is a osteochondrosis of the lesser metatarsal heads. Various surgical treatment have been recommanded including joint debridement and metatarsal head reshaping, metatarsal dorsal wedge osteotomy, metatarsal head excision and joint arthroplasty. Autogenous osteochondral graft for the treatment of Freiberg disease is an effective restorative procedure that provides early range of motion exercise, weight bearing, and reduces other morbidity. We report a case of late stage Freiberg disease treated with arthrotomy, removal of loose body and autogenous osteochondral graft.

Avascular Necrosis of the First Metatarsal Head after Distal Chevron Osteotomy for Hallux Valgus: A Case Report / 대한족부족관절학회지

Avascular necrosis of the first metatarsal head is uncommon. It is most often seen following a distal metatarsal osteotomy for hallux valgus. Although many cases may be subclinical, it is a powerful cause of failure of bunion surgery. Avascular necrosis of the first metatarsal head results in a series of events that begins with phases of avascularity; revascularization, with or without collapse; and reossification. Collapse may result in degenerative change of the metatarsophalangeal joint. We have recently experienced a case of avascular necrosis of the first metatarsal head.

Differences between Radiologic Angle & Real Angle of Distal Metatarsal Articular Surface Angle / 체질인류학회지

Selection of the surgical procedure for Hallux Valgus is decided after variable factors including radiologic indices were considered. Among them, congruency of the first metatarsophalangeal [MTP] joint is important factor to get the better prognosis. Articular surface angle of first metatarsal head [AAMH] has been used to substituted for first MTP joint congruency. But there had been questions whatever that the value of AAMH measured radiologically equal to real angle in surgical field. The purpose of this article is to compare clinically used radiologic angle of AAMH to real anatomical angle in patients operated by. From march to october 1998, among the 75 patients operated by surgical method (Proximal Chevron), measures anatomical AAMH of 25 volunteer at random. Average age was 46.4 yrs old, ratio of the sample is Right : Left = 9 : 16. The radiologic AAMH measured by AOFAS (American Orthopedic Foot and Ankle Society) research committee method 1992 in the weight bearing foot AP film. The actual AAMH is measured directly in the operative field. After the capsular incision had done, first metatarsal head was dislocated totally. K -wire was inserted to articular dome of the metatasal head from medial to lateral, The transverse axial plane of K -wire is parallel to plantigrade foot position. Afterthen, printed image was taken using portable image intensifier. Average radiologic value of metatarsal head was 16.8 degree, real value was 23.52 degree. In general, real angle was bigger than radiologic angle. In the 20% of cases, radiologic angle was bigger than real angle. With paired t -test, there was no correlations in each angles (p>0.01). Conclusion; The average real AAMH measured in surgical field was 23.1degree. There was no statistic correlations between the angles radiologically and anatomically. therefore, We conclude that the angle of distal metatarsal articular surface measured radiologically has not the clinical significance to know articular congruency. Consequently We suggested the three dimensional study to know the real angle of articular surface of first metatarsal head clinically as alternative method.

Treatment of Freiberg's Disease with Joint Debridement and Reshaping of Metatarsal Head / 대한정형외과학회잡지

Freibergs disease is avascular necrosis of the second or third metatarsal bone. Since 1914, numerous causes and treatments have been proposed but no definite single cause and treatment method were developed. The simple method, joint debridement could not recover the pathophysiologic condition of Freibergs disease and the destructive method, metatarsal head resection and prosthetic replacement arthroplasty had many postoperative problems. Recently, dorsiflexion osteotomy, which was described by Gauthier and Elbaz for the first time, and joint debridement and reshaping of the metatarsal head, which was described by Mann, were very effective method to manage Freibergs disease. This paper was aimed to evaluate the result of joint debridement and reshaping of the metatarsal head which were relatively simple, less destructive and safe method in treatment of the advanced Freibergs disease. We treated 7 cases of Freibergs disease from August 1993 to March 1997. The results were as follows: 1. All the patients of the last follow-up improved pain. 2. The passive range of motion was increased from 39.1 preoperatively to 57.6 postoperatively. 3. Follow-up X-rays showed no loose body and further metatarsal head destruction. The above results suggested that the joint debridement and reshaping of metatarsal head provided good result in the treatment of advanced Freibergs disease.

Dorsal Closing Wedge Osteotomy in Freiberg's Disease / 대한정형외과학회잡지

This etiology of Freiberg's disease, an idiopathic avascular necrosis of the second metatarsal head, has not been clarified. In 1979, Gauthier and Elbaz treated 53 cases of the advanced Freiberg's disease by a new technique, that is, dorsal closing wedge osteotomy, and their result was successful. Recently, in 1989, Zollinger identified that the load per surface area is concentrated at the dorsal rather than plantar surface of the second metatarsal head during walking by an experimental dynamic study, and this theory explained why the lesion of the disease is confined to the dorsal surface of the second metatarsal head, and provided a basic concept on the dorsal closing wedge osteotomy. The authors reviewed 5 cases of Freiberg's disease treated by dorsal closing wedge osteotomy from September 1989 to February 1994, and the average follow-up period was 2 years and 5 months(range, 12 to 50 months). The results were as follows; 1. All were female, and the average age at the time of operation was 29.4 years(range, 22 to 43 years). 2. All were pain-free at the last follow-up. 3. The range of motion(ROM) of the metatarsophalangeal joint was increased postoperatively; average ROM: preoperative, 33°/ postoperative 77°; mean gain of ROM, 44° So, dorsal closing wedge osteotomy is a recommendable procedure for the treatment of advanced Freiberg's disease.