Braquimetatarsia: propuesta de tratamiento en base a técnicas de alargamiento: a propósito de dos casos / Brachymetatarsia: treatment proposal based on lengthening techniques: about two cases / Braquimetatarsia: proposta de tratamento baseada em técnicas de alongamento: sobre dois casos

Braquimetatarsia es el acortamiento anormal de uno o más metatarsianos. Tiene una incidencia de 0.02%-0.05% predominando en mujeres de 25 a 1. En un 72% puede ser bilateral. La etiología no es clara pero se plantea el cierre prematuro de la fisis dando un retardo en el crecimiento. La mayoría de las veces presenta síntomas causados por alteración en la mecánica de la parábola metatarsal como dolor e hiperqueratosis. Puede existir metatarsalgia y agregar en la evolución desviaciones digitales adicionales. El principal motivo de consulta es estético. El objetivo del reporte es mostrar dos técnicas quirúrgicas y los resultados clínicos correspondientes usando el score AOFAS, además de los resultados imágenológicos con hasta 5 años de seguimiento. Se describen dos pacientes y se analizan dos técnicas quirúrgicas diferentes para alargar los metatarsianos. Se trata de alargamientos agudos con interposición de injerto intercalar, en un caso mediante el procedimiento de Sandro Gianini con injerto de cresta ilíaca y en el otro con injerto de metatarsiano adyacente con modificación de la longitud del segundo y tercer metatarsiano restituyendo en ambos casos la parábola metatarsal. Obtuvimos buenos resultados al igual que series numerosas pudiendo recomendarse en casos similares.

Brachymetarsal is the abnormal shortening of one or more metatarsals. It has an incidence of 0.02%-0.05%, predominantly in women from 25 to 1. In 72% it can be bilateral. The etiology is not clear, but premature closure of the physis is suggested, giving growth retardation. Most of the time it presents symptoms caused by an alteration in the mechanics of the metatarsal parabola, such as pain and hyperkeratosis. There may be metatarsalgia and add additional digital deviations in the evolution. The main reason for consultation is aesthetic. The objective of the work is to show the surgical technique and the clinical results using the AOFAS score, in addition to the imaging results with up to 5 years of follow-up. Two patients are described and two different surgical techniques to lengthen the metatarsals are analyzed. These are acute lengthenings with intercalary graft interposition, in one case using the S.Gianini procedure with an iliac crest graft and in the other with an adjacent metatarsal graft with modification of the length of the second and third metatarsals, restoring in both cases the metatarsal parabola. We obtained good results. results as well as numerous series and can be recommended in similar cases.

Braquimetatarsal é o encurtamento anormal de um ou mais metatarsos. Tem incidência de 0,02%-0,05%, predominantemente em mulheres de 25 a 1 ano. Em 72% pode ser bilateral. A etiologia não é clara, mas sugere-se o fechamento prematuro da fise, causando retardo de crescimento. Na maioria das vezes apresenta sintomas decorrentes de uma alteração na mecânica da parábola metatarsal, como dor e hiperqueratose. Pode haver metatarsalgia e adicionar desvios digitais adicionais na evolução. O principal motivo da consulta é a estética. O objetivo do trabalho é mostrar a técnica cirúrgica e os resultados clínicos utilizando o escore AOFAS, além dos resultados de imagem com até 5 anos de seguimento. Materiais e métodos: São incluídos dois pacientes e analisadas duas técnicas cirúrgicas diferentes para alongar os metatarsos. São alongamentos agudos com interposição de enxerto intercalar, em um caso utilizando a técnica de S. Gianini com enxerto de crista ilíaca e no outro com enxerto de metatarso adjacente com modificação do comprimento do segundo e terceiro metatarsos, restaurando em ambos os casos o metatarso parábola. Obtivemos bons resultados, bem como inúmeras séries, podendo ser recomendados em casos semelhantes.

Percutaneous minimally invasive osteotomy with 8-shaped bandage and hallux valgus splint fixation for the treatment of moderate hallux valgus / 中国骨伤

OBJECTIVE@#To observe clinical effect of percutaneous minimally invasive osteotomy with 8-shaped bandage and hallux valgus splint fixation in treating moderate hallux valgus.@*METHODS@#Totally 23 patients with moderate hallux valgus were treated with percutaneous minimally invasive osteotomy with 8-shaped bandage and hallux valgus splint fixation from August 2019 to January 2021, and 1 patient was loss to follow-up, and finally 22 patients(30 feet) were included, 4 males (6 feet) and 18 females(24 feet), aged from 27 to 66 years old with an average of(50.59±11.95) years old. Hallux valgus angle (HVA), intermetatarsal angle (IMA), metatarsal span (the distance between the first and the fifth metatarsal bones), changed of soft tissue width, American Orthopaedic Foot and Ankle Society(AOFAS) score, and Visual Analogue Scale (VAS) were collected and compared before operation and 6 months after operation.@*RESULTS@#Twenty-two patients were followed up from 5.7 to 6.4 months with an average of (6.13±0.85) months. The first metatarsal osteotomy of patients were obtained bone union, and deformity of the toes was corrected. Complications such as avascular necrosis of metatarsal head and transfer metatarsalgia were not occurred. Postoperative HVA, IMA, metatarsal span, soft tissue width, VAS, AOFAS score at 6 months were significantly improved compared with pre-operation (P<0.01). According to AOFAS score at 6 months after operation, 10 feet were excellent, 18 good and 2 poor. Two feet with poor were excellent after prolonged 8-shaped bandage and hallux valgus splint fixation time.@*CONCLUSION@#Percutaneous minimally invasive osteotomy with 8-shaped bandage and hallux valgus splint fixation for the treatment of moderate hallux valgus could better correct deformity of hallux valgus, relieve foot symptoms, good recovery of postoperative function, and has a significant clinical efficacy.

Fracturas de la base del quinto metatarsiano: ¿es útil mi tornillo de esponjosa con rosca parcial? Experiencia de 10 años / Fractures of the base of the fifth metatarsal bone: is my partially-threaded cancellous screw useful? 10-year experience

OBJETIVO Evaluar el resultado quirúrgico de fracturas de las zonas 2 y 3 de la base del quinto metatarsiano usando tornillos de esponjosa de diámetro de 4,0 mm con rosca parcial. MATERIALES Y MÉTODOS Evaluación retrospectiva de pacientes operados entre 2010 a 2019. Incluimos todos los casos sintetizados con este dispositivo con seguimiento mínimo de tresmeses, y excluimos casos operados con otros dispositivos y seguimiento menor a tres meses. Evaluamos la consolidació n y la presencia de complicaciones. Determinamos el largo del tornillo, el diámetro del canal endomedular, la distancia entre el borde proximal de la tuberosidad y la fractura, y la distancia de paso de la rosca sobre el rasgo de la fractura en radiografías anteroposterior (AP) y oblicua del pie. RESULTADOS Evaluamos 39 casos, y la muestra tenía una edad promedio de 27 años, y predominio del sexo masculino. El largo de tornillo más usado fue el de 45 mm, y los diámetros promedios del canal endomedular medidos en las radiografías AP y oblicua fueron de 4,6 mm y 3,96 mm, respectivamente. La distancia del borde de la tuberosidad hasta la fractura fue de 25,8 mm, y la distancia de paso de la rosca sobre el rasgo de la fractura fue en promedio de 24 mm. Hubo 100% de consolidación, en un promedio de 9,4 semanas, y 3 casos de retardo de consolidación, 2 de retroceso de tornillo, 1 de rosca intrafoco, y 1 de fractura cortical superior. No hubo retiros de tornillos a la fecha. DISCUSION No existe consenso respecto al tornillo ideal. La literatura internacional recomienda dispositivos intramedulares de diámetro de al menos 4,5 mm. Existen pocos reportes del uso de tornillos de diámetro de 4,0 mm. CONCLUSIONES El tornillo de esponjosa de diámetro de 4,0 mm con rosca parcial es una alternativa eficaz, segura y con baja tasa de complicaciones para el manejo de estas fracturas en nuestra población.

OBJETIVE To evaluate the surgical result of zone-2 and -3 fractures of the base of the fifth metatarsal bone using partially-threaded cancellous screws with a diameter of 4.0 mm. MATERIALS AND METHODS A retrospective evaluation of patients submitted to surgery between 2010 and 2019. We included all of the cases synthesized with this device with a minimum follow-up of three months, and excluded the cases operated on with other devices and follow-up shorter than three months. We evaluated the consolidation and the presence of complications, and determined, screw length, diameter of the endomedullary canal, the distance between the proximal edge of tuberosity and the fracture, and thread pitch over the fracture line on anteroposterior (AP) and oblique radiographs. RESULTS We evaluated 39 cases, and the sample had an average age of 27 years and male predominance. The most used screw length was 45 mm, and the average diameters of the medullary canal measured on the AP and oblique radiographs were of 4.6 mm and 3.96 mm respectively. The distance from the edge of the tuberosity to the fracture was of 25.8 mm, and the thread pitch over the fracture line was on average 24 mm. The rate of consolidation was of 100%, occurring in an average of 9.4 weeks, and there were 3 cases of consolidation delay, 2 of screw recoil, 1 of intrafocus thread, and 1 of superior cortex fracture. To date, there have been no cases of screw removal. DISCUSSION There is no consensus regarding the ideal screw. The international literature recommends intramedullary devices with a diameter of at least 4.5 mm. There are few reports of the use of screws with 4.0 mm in diameter. CONCLUSIONS The partially-threaded cancellous screw with a diameter of 4.0 mm is an effective and safe option, with a low complication rate for the management of these fractures.

Clinical analysis of external micro-locking plate in the treatment of fifth metatarsal comminuted fractures / 中国骨伤

OBJECTIVE@#To explore the clinical efficacy of external micro-locking plate combined with closed reduction in the treatment of fifth metatarsal comminuted fracture with severe soft tissue injury.@*METHODS@#From January 2018 to December 2019, 13 patients received micro-locking plate combined with closed reduction treatment due to the fifth metatarsal comminuted fracture with severe soft tissue injury. There were 11 males and 2 females patients, ranging in age from 21 to 69 years. According to the fracture AO fracture classification, 9 cases belonged to type 87(S)-C2.2 and 4 cases belonged to type 87(S)-C2.1. The fifth metatarsal cuneiform articular surface was not involved, and all of them were comminuted fractures of the fifth metatarsal shaft. All soft tissues were damaged to varying degrees. Three patients got small defect of skin and soft tissue, and they were treated with debridement and suture after one-stage emergency surgery. The fracture healing and complications were observed, and the clinical efficacy was evaluated according to the midfoot function score of American Orthopaedic Foot & Ankle Society (AOFAS) at the latest follow-up.@*RESULTS@#All patients were followed up, and the duration ranged from 3 to 12 months. One patient had delayed union. One patient had local skin necrosis and was treated with second-stage skin grafting to repair the wound surface. No external screw breakage or infection was reported, the skin soft tissue healed satisfactorily and reached bony union, with the union time ranging from 8 to 19 weeks. The postoperative functional recovery was rated according to the midfoot score of AOFAS, the score ranged from 49 to 98, and 7 patients got an excellent result, 4 good, 1 fair and 1 poor.@*CONCLUSION@#The external micro-locking plate combined with closed reduction in the treatment of fifth metatarsal comminuted fracture with severe soft tissue injury has the advantages of simple operation, good stability and low infection rate, which is helpful to the repair of soft issue injury, and the fixation can be removed early in outpatient clinic. To sum up, this surgical procedure is suitable for patients with severe soft tissue injury and comminuted fracture to avoid periosteum stripping. The space occupying is smaller than the micro-external fixator, which is convenient for patients with early functional exercise.

Rotating Scarf osteotomy in treating hallux valgus combined with the first metatarsal rotation / 中国骨伤

OBJECTIVE@#To explore clinical effect of rotational Scarf osteotomy in treating hallux valgus (HV) with rotation of the first metatarsal bone.@*METHODS@#From January 2018 to October 2019, 35 patients (40 feet) with HV and rotation deformity of the first metatarsal were treated with rotational Scarf osteotomy, including 5 males and 30 females;aged from 25 to 76 years old with an average of (40.32±5.43) years old. Hallux valgus angle(HVA), intermetatarsal angle (IMA), distal metatarsal articular angle (DMAA), the first metatarsal length (FML) were observed and compared, American Orthopedic Foot and Ankle Society(AOFAS) of hallux metatarsophalangeal interphalangeal joint score and visual analogue scale (VAS) were used to evaluate functional evaluation.@*RESULTS@#Thirty-five patients(40 feet) were followed up from 12 to 36 months with an average of (14.35±3.62) months. HVA, IMA and DMAA were corrected from (36.32±4.51) °, (14.21±3.22) ° and (28.35±4.32) ° before operation to (14.32±5.71) °, (5.83±3.97) ° and (7.32±2.14) ° after operation respectively (P<0.05). There was no satistical difference in FML before and after operation (P>0.05). AOFAS score and VAS improved from (57.00±4.31) and (6.00±1.21) before operation to (90.31±3.28) and (1.42±0.83) after operation, respectively, and had significant difference(P<0.05);according to AOFAS score, 23 feet got excellent results, 15 feet good and 2 feet fair.@*CONCLUSION@#Rotational Scarf osteotomy with strong correction and high dimension could effectively correct HV combined with rotation deformity of the first metatarsal bone, improve function of the forefoot, and obtain good clinical results.

Scarf osteotomy combined with soft tissue balance release for severe hallux valgus / 中国骨伤

OBJECTIVE@#To explore clinical effect of Scarf osteotomy combined with soft tissue balance in treating severe hallux valgus.@*METHODS@#Totally 38 patients(50 feet) with severe hallux valux who underwent Scarf osteotomy combined with soft tissue balance surgery from June 2019 to June 2021 were retrospectively analyzed, aged from 29 to 64 years old with an average of(54.7±6.8) years old; 26 feet on the left side and 24 feet on the right side;the courses of disease ranged from 5 to 23 years with an average of (12.4±3.9) years. Hallux valgus angle (HVA), intermetatarsal angle (IMA), and distal metatarsal articular angle (DMAA) were compared before and after operation, and postoperative complications was observed. American orthopedic foot ankle society(AOFAS) score before operation and final follow-up was used to evaluate recovery of forefoot function, and visual analogue scale (VAS) was used to evaluate pain relief.@*RESULTS@#Thirty-eight patients (50 feet) were followed up from 15 to 23 months with an average of (18.3±3.2) months. Preoperative HVA, IMA and DMAA were (44.61±3.92)°, (18.74±2.51)°, (12.85±2.11)°, and improved to (13.45±2.13)°, (7.83±1.36)°, (7.03±1.39)°at final follow-up, which had statistical differneces(P<0.05). No delayed union or nonunion of osteotomy end, fracture or loosening of internal fixation, hallux varus occurred. VAS and AOFAS score improved from (6.81±2.14), (43.6±8.4)points before operation to (1.97±0.78), (87.6±5.2) points at final follow-up, which had statistical difference(P<0.01). According to AOFAS at final follow-up, 20 feet got excellent result, 28 feet good and 2 feet moderate.@*CONCLUSION@#Scarf osteotomy combined with soft tissue balance release for severe hallux valgus has good stability and corrective effect, but learning curve and postoperative complications should be paid attention.

The first metatarsophalangeal joint fusion combined with lateral toe rotation Weil osteotomy for hallux valgus with severe metatarsal adduction / 中国骨伤

OBJECTIVE@#To explore clinical effect of the first metatarsophalangeal joint fusion combined with lateral toe rotation Weil osteotomy in treating hallux valgus with severe metatarsal adduction.@*METHODS@#From March 2017 to August 2021, 37 patients ( 69 feet ) with severe plantar adductor hallux valgus were treated with the first metatarsophalangeal joint fusion combined with rotational Weil osteotomy were retrospectively analyzed, including 8 males(11 feet) and 29 females (58 feet), aged from 67 to 83 years old with an average of (70.03±2.87) years old;3 cases on the left side, 2 cases on the right side and 32 cases on both sides. Visual analogue scale(VAS) was used to evaluate degree of pain relief before operation, 6 weeks after operation and at the final follow-up. American Orthopaedic Foot and Ankle Surgery (AOFAS) forefoot score was used to evaluate function of the affected foot before operation and final follow-up. Hallux valgus angle(HVA) and intermetatarsal angle(IMA) were measured before operation and at the final follow-up.@*RESULTS@#Thirty-seven patients(69 feet) were followed up from 12 to 48 months with an average of(22.8±0.6) months. Bone healing was achieved at the first metatarsophalangeal joint from 7 to 10 weeks with an average of (8.00±1.21) weeks after operation, without delay and nonunion. HVA was increased from (44.30±2.84)° before operation to (15.20±2.13) °at the final follow-up, and had statistical difference(t=65.781, P<0.05);while no difference in IMA before and after operation(P>0.05). VAS was decreased from (6.73±1.48) points to (2.78±0.71) points at 6 months after operation(t=3.279, P<0.05), and had difference compared with the latest follow-up(1.16±1.12)(t=4.859, P<0.05). AOFAS forefoot score increased from (52.14±5.78) preoperatively to (86.70±4.86) at the fonal follow-up, and 25 feet got excellent results, 40 feet good and 4 feet fair.@*CONCLUSION@#The first metatarsophalangeal joint fusion combined with lateral toe rotation Weil osteotomy in treating severe plantar adduction hallux valgus could significantly relieve pain and appearance of forefoot, stabilize the first sequence, and significantly improve walking function.

Case-control study on Scarf and double metatarsal osteotomy of the first metatarsal for the treatment of hallux valgus deformity / 中国骨伤

OBJECTIVE@#To compare clinical efficacy of scarf osteotomy and double metatarsal osteotomy(DMO) in treating moderate to severe hallux valgus.@*METHODS@#Fifty patients (81 feet) with moderate to severe hallux valgus deformity were treated from January 2017 to December 2019, and were divided into Scarf osteotomy (SO) group or DMO group according to different osteotomy methods. There were 26 patients (44 feet) in SO group, including 1 male and 25 females, aged from 48 to 65 years old with an average of (55.5±4.67) years old;18 patients (30 feet) with moderate and 8 patients (14 feet) with severe. There were 24 patients(37 feet) in DMO group, including 1 male and 23 females, aged from 45 to 62 years old with an average of (52.1±6.8) years old;there were 14 patients (24 feet) with moderate and 10 patients (13 feet) with severe. Hallux valgus angle (HVA), intermetatarsal angle (IMA), distal metatarsal articular angle (DMAA) and relative length of the first metatarsal(RLFM) on weight-bearing anteroposterior radiographs before and after operation were compared. American Orthopaedic Foot and Ankle Society (AOFAS) hallux, metatarsal, and interphalangeal joint scores was used for evaluate clinical effects. Weight bearing time and complications were observed.@*RESULTS@#Fivty patients were followed up. The follow-up time in SO group ranged from 12 to 36 months with an average of(20.50±6.22) months and from 16 to 28 months with an avaerge of(19.80±2.44) months in DMO group while there was no significant difference between two groups(P>0.05). All incision healed at stage I, and osteotomy healed at (20.31±3.17) months after operation. One patient occurred hallux adduction deformity, without transferred metatarsalgia;2 patients occurred metastatic metatarsalgia in DMO group. There were no significant difference in HVA, IMA, DMAA, and AOFAS scores between two groups(P>0.05) before and after operation. There was no significant difference in RLFM between two groups(P>0.05), while had significant difference in RLFM between two groups at final follow-up (P<0.05). Partial weight-bearing time and full weight-bearing time in SO group were significantly earlier than those in DMO group (P<0.05).@*CONCLUSION@#Both of Scarf osteotomy and the first metatarsal biplane osteotomy could effectively treat moderate to severe hallux valgus deformity, with similar imaging and clinical evaluation. However, the relative length of the first metatarsal bone in SO group was longer than that in DMO group after operation, and the time of weight bearing in Scarf osteotomy is earlier than that of double metatarsal osteotomy of the first metatarsal.

Modified Chevron osteotomy in the treatment of moderate and severe hallux valgus / 中国骨伤

OBJECTIVE@#To investigate the method and clinical effect of modified Chevron osteotomy of the distal end of the first metatarsal in the treatment of moderate and severe hallux valgus.@*METHODS@#From January 2015 to January 2019, 28 patients(30 feet) with moderate and severe hallux valgus were treated with modified Chevron osteotomy combined with lateral soft tissue release of the first metatarsophalangeal joint, including 2 males (2 feet) and 26 females (28 feet). The age ranged from 35 to 74 (57.3±9.3) years;10 feet on the left, 16 feet on the right, 2 cases on both sides(4 feet);the course of disease was 3 to 12 (9.32±3.89) years. The changes of hallux valgus angle(HVA), intermetatarsal angle(IMA) between the first and second metatarsals and distal metatarsal articular angle(DMAA) of the first metatarsal were measured and compared before and 6 months after operation. The American Orthopaedic Foot and Ankle Society(AOFAS) thumb joint scoring system was used to evaluate the curative effect.@*RESULTS@#All 28 patients were followed up for 8 to 16 (11.28±3.42) months. The incision healed well in all patients, and there were no complications such as incision infection and metatarsal head necrosis. The healing time of osteotomy site was 6 to 10(7.12±1.34) weeks. Preoperative HVA, IMA, DMAA and AOFAS were (36.06±6.02) °, (21.78±4.16) °, (8.21±2.65) ° and (52.90±10.97) respectively, at six months after operation, they were (8.87±2.46) °, (11.66±2.84) °, (3.65±1.00) ° and (87.45±10.55) respectively, there was significant difference between preoperative and 6 months after operation(P<0.05). At 6 months after operation, AOFAS score was excellent in 20 feet, good in 7 feet and poor in 3 feet. Among the 3 patients with poor scores, 2 were excellent after revision, and 1 was significantly improved after using custom insoles.@*CONCLUSION@#Modified Chevron can effectively correct HVA, IMA and DMAA and improve functional recovery. The modified Chevron osteotomy increases the moving distance and the contact of the osteotomy surface. It can be fixed with multiple screws, has strong correction ability, and can exercise early. It is one of the optional methods for the treatment of moderate and severe hallux valgus.

Percutaneous Hallux Valgus: An Algorithm for the Surgical Treatment / Hálux valgo percutâneo: Um algoritmo de tratamento cirúrgico

Abstract Objective To present the clinical and radiographic results of hallux valgus surgical correction using four percutaneous techniques, chosen according to a predefined radiographic classification. Methods We prospectively evaluated 112 feet in 72 patients with hallux valgus operated over the course of 1 year. Percutaneous distal soft tissue release (DSTR) and the Akin procedure (DSTR-Akin) were performed in mild cases. In mild to moderate hallux valgus with distal metatarsal joint angle > 10°, we added the Reverdin-Isham (RI) osteotomy. In moderate cases with joint incongruity, we performed the percutaneous chevron (PCH). Finally, a Ludloff-like percutaneous proximal osteotomy fixed (PPOF) with a screw was proposed in severe cases with an intermetatarsal angle (IMA) > 17°. According to these criteria, 26 DSTRs-Akin, 36 PCHs, 35 RIs, and 15 PPOFs were performed. The mean follow-up was of 17.2 months (range: 12 to 36 months). The mean age at operation was 58.8 years (range: 17 to 83 years), and 89% of the patients were female. Results The mean preoperative hallux valgus angle (HVA) and the IMA decreased from 21° to 10.2° and from 11.2° to 10.3° respectively in the DSTR-Akin. In the RI, the mean HVA decreased from 26.6° to 13.7°, and the IMA, from 11.2° to 10.3°; in the PCH, the mean HVA decreased from 31° to 14.5°, and the IMA decreased 14.9° to 10.7°; as for the PPOF, the mean HVA decreased from 39.2° to 17.7°, and the IMA, from 11.8° to 6.8°. The average ankle and hindfoot score of the American Orthopaedic Foot and Ankle Society (AOFAS) increased from 49.2 to 88.6. The rate of complications was of 11%. Conclusion Our treatment protocol does not differ much from the classic ones, with similar results as well. We have as advantages less aggression to soft tissues and better cosmetic results. Level of Evidence: level IV, prospective case series.

Resumo Objetivo Apresentar os resultados clínicos e radiográficos da correção cirúrgica de hálux valgo utilizando quatro técnicas percutâneas escolhidas de acordo com uma classificação radiográfica predefinida. Métodos Avaliamos prospectivamente 112 pés em 72 pacientes com hálux valgo operado em um período de um ano. A liberação de tecido mole distal (LTMD) percutâneo e o procedimento de Akin (LTMD-Akin) foram realizados em casos leves. Em hálux valgo de leve a moderado com ângulo distal da articulação do metatarso acima de 10°, adicionamos a osteotomia de Reverdin-Isham (RI). Em casos moderados com incongruência articular, realizamos o chevron percutâneo (CHP). Finalmente, uma osteotomia proximal percutânea fixada (OPPF) com um parafuso, semelhante à de Ludloff, foi proposta em casos graves com ângulo intermetatarsal (AIM) acima de 17°. De acordo com esses critérios, foram realizados 26 LTMDs-Akin, 36 CHPs, 35 RIs e 15 OPPFs. O seguimento médio foi de 17,2 meses (12 a 36 meses). A média de idade em operação foi de 58,8 anos (17 a 83 anos), e 89% dos pacientes eram do sexo feminino. Resultados A média do ângulo de hálux valgo (AHV) pré-operatório e o AIM diminuíram de 21° para 10,2°, e de 11,2° para 10,3°, respectivamente, em casos de LTMD-Akin. Em casos de RI, a média do AHV diminuiu de 26,6° para 13,7°, e o AIM, de 11,2° para 10,3°; em casos de CHP, o AHV médio diminuiu de 31° para 14,5°, o AIM diminuiu de 14,9° para 10,7°, e a OPPF, de 39,2° para 17,7°, e o AIM 11,8° para 6,8°. A média do escore de tornozelo e retropé da American Orthopaedic Foot and Ankle Society (AOFAS) aumentou de 49,2 para 88,6. A taxa de complicação foi de 11%. Conclusão Nosso protocolo de tratamento não difere muito dos clássicos, com resultados semelhantes. Temos como vantagem menos agressividade aos tecidos moles e melhores resultados cosméticos. Nível de evidência: nível IV, série de casos prospectivos.

Minimally invasive osteotomy and manual reduction for hallux valgus / 中国骨伤

OBJECTIVE@#To explore clinical effects of minimally invasive osteotomy and manual reduction in treating hallux valgus.@*METHODS@#From January 2018 to May 2019, 31 patients (42 feet) with hallux valgus were treated with minimally invasive osteotomy and manual reduction, including 3 males and 28 females aged from 18 to 76 years old with an average of (50.1± 4.9) years old. Preoperative and postoperative hallux valgus (HVA), intermetatarsal angles(IMA), length difference between 1 and 2 metatarsals were recorded and compared, and American Orthopedic Foot and Ankle Society (AOFAS)score were observed and measured.@*RESULTS@#Thirty-one patients (42 feet) were followed up from 14 to 18 months with an average of (15.1± 1.2) months. HVA, IM before operation were (38.5±5.4)°, (13.0± 1.1)°, and improved to (14.3±4.7)°and (9.1±1.5)°after operation respectively(@*CONCLUSION@#Minimally invasive osteotomy and manual reduction in treating hallux valgus have advantages of shorter operation time, less length of incision, and could correct hallux valgus deformity, improve front feet and receive good clinical effect in further.

Corrección del componente rotacional prequirúrgico y postquirúrgico del primer metatarsiano secundario a osteotomía de Chevron modificado / Correction of the pre- and post-surgical rotational component of the first metatarsal secondary to modified Chevron osteotomy

Resumen: Introducción: Hallux valgus (HV) es una patología compleja del antepié, recientemente se ha mostrado interés en el componente rotacional (CR) distal del primer metatarsiano por su relación con recidivas postquirúrgicas de la deformidad. La selección de la técnica quirúrgica es controversial con escasa literatura acerca de la corrección de rotación con osteotomías comunes. Nuestro objetivo es evaluar características radiológicas prequirúrgicas y postquirúrgicas respecto a CR del primer metatarsiano en la cirugía de corrección de HV moderado a severo usando osteotomía de Chevron largo. Material y métodos: Estudio observacional, prospectivo y comparativo en el que se evaluó el CR del primer metatarsiano en nueve pies pertenecientes a seis pacientes con una edad media de 45 años. El CR fue evaluado con base en la metáfisis proximal del primer metatarsiano en fluoroscopías axiales sin carga y AP de pie. Las mediciones se realizaron por un residente de ortopedia y traumatología y un subespecialista en cirugía de pie y Tobillo. Resultados: Se documentaron diferencias significativas (p = 0.05) en el ángulo de pronación prequirúrgico y postquirúrgico al utilizar osteotomía de Chevron largo. El resultado funcional de los pacientes evaluados fue excelente a 11 meses de seguimiento. Conclusiones: Radiológicamente, la corrección rotacional es variable y previamente no se ha reportado en la literatura con esta osteotomía. Se establecen bases morfológicas para la realización de estudios posteriores en la evaluación de rotación de cabeza del primer metatarsiano con diferentes osteotomías.

Abstract: Introduction. Hallux valgus (HV) is a complex forefoot pathology, in which interest has recently been shown in the distal rotational component (CR) of the first metatarsal due to its relationship with postsurgical relapses of the deformity. The selection of surgical technique is controversial with little current literature on the correction of rotation with common osteotomies. The aim of this study is to evaluate preoperative and postoperative radiological characteristics regarding CR of the first metatarsal using long Chevron osteotomy for moderate to severe HV. Material and methods: An observational, prospective and comparative study was carried out in which the CR of the first metatarsal was evaluated in nine feet belonging to six patients with a mean age of 45 years. The RC was evaluated based on the proximal metaphysis of the first metatarsal in axial fluoroscopies of unloaded metatarsals and standing AP. Measurements were performed by an Orthopedic and Traumatology resident and a Foot and Ankle Surgery subspecialist. Results: Significant differences (p = 0.05) were documented in the preoperative and postoperative pronation angle when using long Chevron osteotomy. The functional result of the evaluated patients was excellent at 11 months of follow-up. Conclusions: Radiologically, the rotational correction is variable and has not previously been reported in the literature with this osteotomy. We establishes the morphological bases for the performance of subsequent studies in the evaluation of head rotation of the 1st metatarsal with different osteotomies.

Alargamiento óseo con minitutor externo como tratamiento de braquimetatarsianos / Bone lengthening with external mini-fixator as treatment for brachymetatarsals

Introducción: La braquimetatarsia es un acortamiento de algún metatarsiano, debido principalmente a una detención prematura del crecimiento de la fisis. Es más frecuente en mujeres, y afecta, sobre todo, al cuarto y al primer metatarsiano. El objetivo de este estudio fue evaluar los resultados del tratamiento mediante alargamiento óseo progresivo con minitutor externo. Materiales y Métodos: Estudio descriptivo retrospectivo. Serie de casos. Se analizaron los resultados de los pacientes operados con esta técnica en nuestro Centro. Se analizaron 6 casos, dos con braquimetatarsia bilateral. Todas eran mujeres y tenían braquimetatarsia del 4.° metatarsiano. El promedio de edad era de 14 años. Se evaluaron los siguientes aspectos: alargamiento en milímetros y complicaciones, como retraso de la consolidación, infección, luxación metatarsofalángica, articulación metatarsofalángica en flexión y satisfacción del paciente. Resultados: Se logró un alargamiento promedio de 15 mm. Dos pacientes tuvieron una infección superficial de las agujas. Una paciente evolucionó con luxación de la articulación metatarsofalángica; otra, con flexión de la articulación metatarsofalángica. No hubo complicaciones neurovasculares. Conclusiones: El alargamiento óseo guiado con tutor externo es un tratamiento seguro y eficaz, además lograría un largo mayor en milímetros que el alargamiento en un tiempo, con un mejor control del alargamiento de partes blandas y estructuras neurovasculares. Todas las complicaciones se resolvieron de manera simple, no afectaron el resultado final del tratamiento. Las complicaciones concuerdan con las descritas en la literatura internacional. Nivel de Evidencia: IV

Introduction: Brachymetatarsia is a shortening of any metatarsal bone, mainly due to premature growth arrest of the growth plate. It is more frequent in women, the fourth and the first metatarsal being the most affected bones. The aim of this study was to evaluate the outcomes of progressive bone lengthening with external mini-fixator. Methods: This is a retrospective, descriptive, case series study in which we analyzed the outcomes of all patients operated on with this technique in our Center. Six cases were evaluated, two of them presented bilateral brachymetatarsia. All patients were women, and had brachymetatarsia of the 4th metatarsal. The average age was 14 years. The following aspects were evaluated: lengthening in millimeters and presence of complications, such as delayed consolidation, infection, metatarsophalangeal joint dislocation, metatarsophalangeal joint in flexion and patient satisfaction. Results: On average, an increase of 15 mm was achieved. Two cases presented superficial infection at the needle insertion site. One patient progressed to metatarsophalangeal joint dislocation, and another one to metatarsophalangeal joint flexion. No neurovascular complications were observed. Conclusions: Bone lengthening with external fixator is a safe and effective treatment. A greater length in millimeters can be achieved in comparison to one-stage lengthening, as well as an improved soft-tissue neurovascular stretching. All complications resolved smoothly and did not affect final treatment results. Complications are similar to those described in the international literature. Level of Evidence: IV

Intermittent vibrations accelerate fracture healing in sheep

Abstract Purpose: To investigate the effect of intermittent vibration at different intervals on bone fracture healing and optimize the vibration interval. Methods: Ninety sheep were randomized to receive no treatment (the control group), incision only (the sham control group), internal fixation with or without metatarsal fracture (the internal fixation group), and continuous vibration in addition to internal fixation of metatarsal fracture, or intermittent vibration at 1, 2, 3, 5, 7 and 17-day interval in addition to internal fixation of metatarsal fracture (the vibration group). Vibration was done at frequency F=35 Hz, acceleration a=0.25g, 15 min each time 2 weeks after bone fracture. Bone healing was evaluated by micro-CT scan, bone microstructure and mechanical compression of finite element simulation. Results: Intermittent vibration at 7-day interval significantly improved bone fracture healing grade. However, no significant changes on microstructure parameters and mechanical properties were observed among sheep receiving vibration at different intervals. Conclusions: Clinical healing effects should be the top concern. Quantitative analyses of bone microstructure and of finite element mechanics on the process of fracture healing need to be further investigated.

Tratamiento integral del antepié con doble braquimetatarsia bilateral en un tiempo quirúrgico. Reporte de un caso / Case report: comprehensive treatment of forefoot with double brachymetatarsia in one surgical stage

Resumen: La braquimetatarsia (acortamiento metatarsal) afecta directamente el arco transverso del pie condicionando graves deformidades como hallux valgus, divergencia digital, dedo supraaducto, metatarsalgia, todas estas alteran la biomecánica del pie y la marcha. El tratamiento se realiza mediante dos técnicas principales, elongación en un solo tiempo quirúrgico con interposición de injerto óseo o elongación por callotaxis con minifijador externo. Existen variantes de ambas técnicas con la finalidad de disminuir las desventajas de cada una de ellas. El objetivo del tratamiento debe ser devolver la armonía estructural del antepié, con lo que mejora la biomecánica, traduciéndose en una evolución satisfactoria para los pacientes. En este artículo se presenta una técnica quirúrgica para pies con fisis cerradas que busca la reestructuración de la fórmula metatarsal y el restablecimiento de la estética y función. En el caso reportado se efectuó alargamiento en un solo tiempo del metatarsiano afectado con interposición de injerto óseo, acortamiento a los metatarsianos adyacentes, corrección del hallux valgus realizando las osteotomías necesarias y el tratamiento de las deformidades de los dedos menores con los métodos requeridos para cada caso. Esta técnica quirúrgica tiene como ventaja la corrección de todo el antepié en un solo tiempo quirúrgico sin necesidad de fijador externo ni de sus cuidados postoperatorios. Sus principales desventajas son la dependencia del injerto óseo estructural y la necesidad de vendaje funcional postquirúrgico hasta la consolidación ósea. En la paciente tratada se obtuvieron resultados clínicos y radiográficos satisfactorios.

Abstract: Brachymetatarsia (shortening of the metatarsal) directly affects the transversal arch of the foot causing severe deformities, such as hallux valgus, divergent toes, overlapping toes, metatarsalgia, all of these alter the biomechanics of the foot and gait. Treatment consists of two main techniques, one-stage lengthening with bone graft or elongation through callotaxis with external fixator; there are variants of both techniques used to minimize the disadvantages of each. The objective of treatment must be to return the structural harmony to the forefoot, improving the biomechanics, resulting in a satisfactory outcome for the patients. This article presents a surgical treatment for feet with closed physis to obtain the appropriate metatarsal formula and to reestablish aesthetics and function. This case was treated by means of one-stage lengthening with bone graft to the affected metatarsal; shortening of the adjacent metatarsals; hallux valgus alignment through the necessary osteotomies and the treatment of deformities of the lesser toes as needed. This surgical technique has as one of its advantages the correction of the entire forefoot at one time, without the need of an external fixator and its required postoperative care. Its main disadvantages are its dependence on structural bone graft and the need of postoperative dressing until healing of the bone has taken place. Satisfactory clinical and radiographical outcomes were obtained in treated patient.

Tratamiento quirúrgico del Hallux Valgus moderado y severo: osteotomía metatarsiana proximal y liberación distal de partes blandas / Surgical Treatment of Moderate to Severe Hallux Valgus: Proximal Metatarsal Osteotomy and Distal Soft Tissue Release

Objetivo: evaluar los resultados clínicos y radiológicos obtenidos con la combinación de la osteotomía proximal del primer metatarsiano y la liberación distal de las partes blandas según técnica de Mann-Coughlin en el tratamiento del hallux valgus moderado y severo. Métodos: estudio retrospectivo en 16 pacientes (30 pies) con hallux valgus moderados y severo, operados en dos Centros Diagnóstico Integral del Estado Apure, en la República Bolivariana de Venezuela, todos por el mismo cirujano, en el período comprendido desde marzo 2009 hasta diciembre 2012. Solo 4 pacientes no continuaron en el seguimiento. Se evaluaron los resultados clínicos y radiográficos. Resultados: se encontró una mejoría promedio de 87,5 puntos según la Escala de la Sociedad Americana de Ortopédicos de Tobillo y Pie (AOFAS por sus siglas en inglés). El ángulo del hallux valgus mejoró de 34,8° promedio a 16,6° y el ángulo intermetatarsiano mejoró de 16,2° a 8,8° después de la cirugía. No hubo hallux varus y solo 2 pacientes tuvieron deshicencia de la herida quirúrgica y un paciente aflojamiento de la aguja Kirschner. Conclusiones: la osteotomía proximal del primer metatarsiano combinada con la liberación distal de partes blandas es una buena opción para la corrección quirúrgica en el tratamiento del hallux valgus moderado y severo, es sencilla para reproducir y presenta similares complicaciones que otras técnicas(AU)

Objective: Evaluate clinical and radiological results obtained with the combination of the first metatarsal osteotomy proximal and distal soft release according Mann-Coughlin technique in the treatment of moderate to severe hallux valgus parts. Methods: A retrospective study was conducted on 16 patients (30 feet) with hallux moderate and severe valgus. They underwent surgery at two Comprehensive Diagnostic Centers in Apure State, in the Bolivarian Republic of Venezuela, by the same surgeon from March 2009 to December 2012. Only four patients did not continue to follow up. Clinical and radiographic results were evaluated. Results: an average of 87.5 points improvement was found according to the scale of the American Society of Orthopaedic Foot and Ankle (AOFAS for its acronym in English). The hallux valgus angle improved from 34.8° to 16.6° and average intermetatarsal angle improved from 16.2° to 8.8° after surgery. There were no hallux varus. Only two patients had dehiscence of the surgical wound, and a patient had loosening of the Kirschner needle. Conclusions: the proximal osteotomy of the first metatarsal combined with distal soft tissue release is a good choice for surgical correction in the treatment of moderate to severe hallux valgus, it is easy to reproduce and it has similar complications than other techniques(AU)

Estudio comparativo de manejo de braquimetatarsia congénita mediante elongación por callotaxis / Comparative study of the management of congenital brachymetatarsia with elongation with callotaxis

La braquimetatarsia consiste en el acortamiento de 5 mm o más del arco parabólico metatarsal del pie, de uno o más de los metatarsianos; se relaciona directamente con el cierre prematuro del cartílago epifisario, o una prematura fusión de la línea epifisaria del extremo distal del metatarsiano, habitualmente el cuarto metatarsiano es el más afectado, predominio en el sexo femenino en relación de 25:1, afección bilateral 72%. Las causas pueden ser congénitas, post traumáticas o como parte de enfermedades específicas. Se realiza estudio prospectivo, comparativo de pacientes con diagnóstico de braquimetatarsia congénita, en el período comprendido de 2007-2008 y 2008-2012; el primer grupo consistió en siete pacientes de los cuales fueron seis niñas, un niño y en el segundo grupo: ocho pacientes, cinco niñas y tres niños. En el primer grupo se obtuvo un alargamiento de 21.1 mm en promedio, en el segundo grupo se obtuvo un alargamiento de 18 mm en promedio sin regresión, distrayendo 0.5 mm por día en ambos grupos. La elongación de los metatarsianos por callotaxis con minifijadores externos es un procedimiento satisfactorio para pacientes adolescentes próximos al cierre epifisario, teniendo mejores resultados con la distracción gradual a 0.5 mm por día.

Brachymetatarsia is the > 5 mm shortening of the metatarsal parabolic arc of the foot, in one or more metatarsals. It is directly related with the early closure of the epiphyseal cartilage or with early fusion of the epiphyseal line of the distal end of the metatarsal. The fourth metatarsal is usually the most affected one. Females are more commonly affected, with a female to male ratio of 25:1; 72% of cases have bilateral involvement. The causes may be congenital, posttraumatic or result from specific conditions. A prospective, comparative study was conducted of patients with a diagnosis of congenital brachymetatarsia seen in 2007-2008 and 2008-2012. Seven patients were included in the former period: six girls and one boy. Eight patients were included in the latter period: five girls and three boys. The mean shortening achieved in the first group was 21.1 mm; in the second one, 18 mm, without regression. The daily distraction in both groups was 0.5 mm. Metatarsal elongation by means of callotaxis with external fixators is an appropriate procedure for adolescent patients about to achieve epiphyseal closure. The best results are obtained with gradual distraction at a rate of 0.5 mm per day.

Manejo quirúrgico del pie cavo anterior en pacientes con Charcot-Marie-Tooth; evolución a 5 años / Surgical management of anterior cavus foot in Charcot-Marie-Tooth patients. Five-year follow-up

La neuropatía hereditaria motora y sensitiva presenta deformidad en los pies, como varo, cavo y dedos en garra. La enfermedad de Charcot-Marie-Tooth tiene descrita diversas técnicas quirúrgicas. Objetivo: Evaluar el resultado clínico y funcional de la osteotomía basal en "V" de los metatarsianos centrales con elevación del primer metatarsiano, osteotomía dorsal más osteotomía de cierre y elevación del quinto metatarsiano en los pacientes de Charcot-Marie-Tooth en un período de cinco años. Material y métodos: Es un estudio prospectivo, aleatorio, longitudinal, observacional y descriptivo en un período comprendido de cinco años. El total de pacientes que cumplieron los criterios de inclusión fueron 24, 16 del sexo masculino y 8 del sexo femenino. Con un total de 34 pies, a siete se les realizó el procedimiento quirúrgico en el pie derecho, a siete en el pie izquierdo y a 10 de manera bilateral, quedando un total de 34 pies tratados. Resultados: Se encontró un coeficiente de correlación de Pearson de -0.1 y una T de 1.71. Con ello se observó una diferencia estadística significativa entre las variables con lo que a los seis meses encontramos que el tratamiento quirúrgico tiene beneficios representativos. Conclusiones: El estudio realizado mostró un valor estadístico significativo tanto en la función, dolor y alineación en pacientes que se sometieron al tratamiento quirúrgico, comparado con el grado previo al evento quirúrgico, por lo que se recomienda continuar con esta técnica en todos los pacientes que sean portadores de pie cavo anterior.

Hereditary sensorimotor neuropathy involves foot deformities such as varus and cavus foot and claw toes. Several surgical techniques have been described to treat Charcot-Marie-Tooth disease. Objective: To assess the clinical and functional result of "V" basal osteotomy of the central metatarsals with elevation of the first metatarsal, dorsal osteotomy plus closing osteotomy, and elevation of the fifth metatarsal in Charcot-Marie-Tooth patients during a five-year period. Material and methods: Prospective, randomized, longitudinal, observational and descriptive study conducted during a five-year period. Twenty-four patients met the inclusion criteria: 16 males and 8 females. Seven underwent the surgical procedure in the right foot, seven in the left, and 10 in both feet, for a total of 34 feet treated. Results: The Pearson correlation coefficient was -0.1 and T = 1.71. A statistically significant difference was seen between the variables, which meant that, in the six-month follow-up, surgical treatment had representative benefits. Conclusions: The study found a statistically significant value for function, pain and alignment in patients who underwent surgical treatment, compared with their status prior to surgery. It is therefore recommended to continue using this technique in all patients presenting with anterior cavus foot.

Osteossíntese com parafuso intramedular nas fraturas proximais do quinto metatarsiano do atleta / Intramedullary screw fixation of proximal fifth metatarsal fractures in athletes

OBJETIVO: Avaliar os resultados clínicos e radiológicos da osteossíntese com parafuso de compressão intramedular nas fraturas proximais do quinto metatarsiano no atleta. MÉTODOS: Foram incluídos no estudo 11 homens e seis mulheres com diagnóstico de fratura das zonas II e III do quinto metatarsiano. Quinze dos pacientes praticavam esporte a nível profissional ou de alto rendimento (futebol: n=11; basquetebol: n=1; atletismo: n=3) e dois praticavam atividade esportiva regular a nível recreacional. Foram submetidos a fixação cirúrgica com parafuso canulado de compressão (4.5mm de diâmetro). Todos os pacientes foram avaliados clinicamente e através da revisão do processo clínico e dos estudos imagiológicos. O tempo médio de seguimento após a cirurgia foi 54 meses (38-70). RESULTADOS: O tempo médio de consolidação (como demonstrado pelo estudo radiológico) e de retorno à atividade esportiva foi 7.3 e 7.5 semanas, respectivamente. Todos os atletas retornaram aos níveis de atividade prévios. Não verificamos atrasos de consolidação, não-união ou refraturas à data do estudo. CONCLUSÃO: A osteossíntese com parafuso de compressão intramedular nas fraturas proximais do quinto metatarsiano demonstrou, nos nossos pacientes, ser um procedimento eficaz com taxas de morbilidade muito reduzidas e que permite ao atleta um retorno precoce à atividade esportiva. Nível de evidência I, Série de Casos.

OBJECTIVE: The purpose of this study was to review the short- and long-term clinical and radiological results of intramedullary compression screw fixation of proximal fifth metatarsal fractures in athletes. METHODS: Eleven male and six female active patients with fifth metatarsal zone II and zone III fractures fixed with a 4.5-mm cannulated compression screw were evaluated by chart review, review of radiographs, and clinical evaluation. Fifteen of the patients were high-level athletes (soccer: n=11; basketball: n=1; track and field: n=3) and two were recreational-level athletes. Mean follow-up from surgery to evaluation was 54 (38-70) months. RESULTS: Mean time to healing as shown on radiographs and mean time to return to full activity after surgery were 7.3 and 7.5 weeks, respectively. All patients were able to return to their previous levels of activity. There were no reports of union delay, nonunion or refracture to date. CONCLUSION: In our patients, cannulated screw fixation of proximal fifth metatarsal fractures was a reliable procedure with low morbidity associated that provided athletes a quick return to activity. Level of Evidence I, Case Series.