Association Between Second Metatarsal Length and Forefoot Loading Under the Second Metatarsophalangeal Joint

Second Metatarsal Length and Transfer Ulcers After First Metatarsal Amputation in Diabetic Foot Infections

BACKGROUND

Plantar transfer ulcers (TUs) underneath the second metatarsal head are frequent after first metatarsal ray amputations due to diabetic foot infections. Whether the second metatarsal length (2ML) is associated with TU occurrence in these patients is unclear. This study evaluated whether 2ML is associated with TU occurrence after first-ray amputations and whether ulcer-free survival is shorter in patients with "excess" 2ML.

METHODS

Forty-two patients with a mean age of 67 (range 33-93) years, diabetes, and first metatarsal ray amputation (first amputation at the affected foot) were included. Two independent readers measured the 2ML using the Coughlin method. A protrusion of more than 4.0 mm of the second metatarsal was defined as "excess" 2ML. The effect of 2ML on ulcer occurrence was analyzed using a multivariate Cox regression model. A Kaplan-Meier curve for TU-free survival was constructed comparing the 2 groups of "normal" (n = 21) and "excess" 2ML (n = 21).

RESULTS

Interrater reliability was excellent. TUs underneath the second metatarsal occurred in 15 (36%) patients. In agreement with our hypothesis, 2ML was nonsignificantly different in patients with TUs, recording a mean of 5.3 (SD 2.5) mm, compared to patients without 4.0 (SD 2.3) mm (hazard ratio [HR] 1.12, 95% CI 0.89-1.41), whereas insulin dependence was associated with ulcer occurrence (HR 0.33, 95% CI 0.11-0.99).

CONCLUSION

In our relatively small study population with a cutoff level of 4 mm for excess 2ML, ulcer-free survival was similar in patients with "normal" and "excess" 2ML.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Establishment and Validation of a Predictive Nomogram for Hallux Valgus with Pain Under the Second Metatarsal

Objective

To investigate the risk factors for hallux valgus complicated with pain under the second metatarsal and construct an effective model and method for predicting hallux valgus complicated with pain under the second metatarsal based on risk factors.

Methods

A total of 545 patients with hallux valgus who were admitted to our hospital were divided randomly into a training set and a validation set. The demographic characteristics, imaging indices and gait test indices of the patients were collected. The risk factors were identified by univariate and multivariate logistic regression analyses. A risk prediction model for hallux valgus with pain under the second metatarsal was established, and the area under the curve (AUC) of the receiver operating characteristic and a decision curve analysis were used for verification and identification. The value of the model was tested in the verification group.

Results

Second metatarsal length, second metatarsal peak pressure, hallux valgus angle (HVA), intermetatarsal angle 1–2 (IMA1–2) and weight were the risk factors for hallux valgus complicated with pain under the second metatarsal. Based on the weighting of these seven risk factors, a prediction model was established. The AUC of the prediction model was 0.84 (95% confidence interval [CI]: 0.802~0.898, P < 0.05), and the results of a Hosmer–Lemeshow test showed a good degree of calibration (χ² = 10.62, P > 0.05). The internal validation of the AUC was 0.83 (95% CI: 0.737–0.885, P < 0.05). The model had obvious net benefits when the threshold probability was 10%–70%.

Conclusion

Second metatarsal length, second metatarsal peak pressure, HVA, IMA1–2 and weight were the risk factors for hallux valgus combined with second metatarsal pain. The risk prediction model for hallux valgus complicated with pain under the second metatarsal based on these seven variables was proven effective.

Level of Evidence

Level III, retrospective comparative study.

Iatrogenic transfer metatarsalgia after hallux valgus surgery: a comprehensive treatment algorithm

Current literature has described many of the complications following hallux valgus surgery and their treatment options.

Iatrogenic transfer metatarsalgia is a distinctive and challenging complication that has not been addressed in a comprehensive fashion yet.

Iatrogenic transfer metatarsalgia may result from poor preoperative assessment, planning and/or surgical technique.

We have classified the causes of iatrogenic transfer metatarsalgia based on a multiplanar assessment of the malalignment(s) and are recommending a comprehensive treatment algorithm to guide surgeons in addressing this complication.

With this knowledge, surgeons may avoid potential pitfalls in the primary surgery that can result in iatrogenic transfer metatarsalgia and find the appropriate treatment option to correct them.

A Critical Biomechanical Evaluation of Foot and Ankle Soft Tissue Repair

The objective of this article is to review the biomechanical stresses that occur during normal physiologic function of lower extremity soft tissue anatomic structures and to use this as a baseline for a critical analysis of the medical literature because it relates to surgical reconstruction following injury. The Achilles tendon, anterior talofibular ligament, plantar plate, and spring ligament are specifically evaluated.

The Impact of Kinesiology Taping on a Greek Foot with a Hammertoe-A Case Report

Background and Objectives: Hammertoe, one of the most common toe deformities, causes pain due to overloading of the periarticular tissues and skin lesions. Additionally, it results in problems with footwear choice, an unattractive foot appearance and a deterioration in quality of life. The most common treatment for rigid and advanced deformities is surgery, and these procedures are widely described in literature. If the changes in the interphalangeal and metatarsophalangeal joints are flexible (that mean they undergo correction without causing pain) or surgery is not possible, conservative treatment should be considered. No research, however, has been found detailing this treatment method. Conservative treatment includes the Kinesiology Taping (KT) method, which involves applying taping to correct deformities. This report describes the effect of KT treatment in a female patient with hammertoes. Materials and Methods: Anthropometric foot measurements (3D scanner) and foot loadings (baropodometric platform) are presented before KT applying, immediately after tapes application and after tapes removal following one month of use. Results: After using KT application parameters such as: foot length, maximum foot load, load under the area of the metatarsals II-III changed. Conclusion: Kinesiology Taping seems to be a symptomatic form of treatment of the effects of lesser toes deformity, therefore it is a good alternative for patients who do not want or cannot undergo surgery.

Comparison of Combination Weil Metatarsal Osteotomy and Direct Plantar Plate Repair Versus Weil Metatarsal Osteotomy Alone for Forefoot Metatarsalgia

Although many surgeons believe that shortening osteotomies are appropriate in patients with metatarsalgia and long second metatarsals, there remains ambiguity regarding when to repair the injured plantar plate and when to leave it alone. We prospectively assessed consecutive adult subjects who underwent an isolated second Weil metatarsal osteotomy (WMO) or a WMO plus plantar plate repair (WMO + PPR) for sub-second metatarsophalangeal joint pain during a 3.5-year period at our practice. Eighty-six patients (86 feet: 21 WMO only and 65 WMO + PPR) with a mean age of 61 ± 11 years were followed for 1 year. Patients were assessed via use of the Foot and Ankle Outcome Score and radiographic parabola/alignment of the operative digit preoperatively and postoperatively. Patients in the WMO + PPR group demonstrated significant improvements preoperatively to postoperatively in 4 of the 5 FAOS subscales (Pain, Other Symptoms, Sport and Recreation Function, and Ankle- and Foot-Related Quality of Life [QoL], all p < .05) and had higher QoL and Pain subscale scores at 1 year compared with those in the WMO-only group (QoL: 68.6 ± 26.7 versus 49.7 ± 28.5, respectively [p = .01]; Pain: 83.2 ± 14.5 versus 73.6 ± 19.9, respectively [p = .04]). The WMO + PPR group tended to have higher-grade tears on intraoperative inspection (median 3, range 0 to 4) compared with those in the WMO group (median 1, range 0 to 3). There were otherwise no group differences in preoperative or postoperative radiographic parabola, alignment of the second toe, or complication rates. Our findings suggest that when a shortening osteotomy is performed, imbricating/repairing and advancing the plantar plate may be valuable regardless of injury grade in the plate.

Minimally invasive distal metaphyseal metatarsal osteotomy (DMMO) for symptomatic forefoot pathology - Short to medium term outcomes from a retrospective case series

BACKGROUND

Minimally invasive distal metaphyseal metatarsal osteotomy (DMMO) may be used to treat metatarsalgia and forefoot pathology. Few large series report its results or examine the degree of metatarsal shortening with this technique. The clinical and radiographic results of a cohort of patients treated with DMMOs at our unit are reported.

METHODS

This was a single-centre retrospective study looking at the outcome of consecutive patients undergoing DMMOs. Demographics, radiological and clinical outcomes, complications and patient reported outcome measures (PROMs) were analysed.

RESULTS

DMMOs on 106 toes in 43 feet were included. Mean age was 60.2±10.2 years and median follow-up was 38 months. Concurrent procedures were performed in 26 cases (60%). DMMO was performed on multiple toes in 42 cases (97%). Mean shortening achieved was 3.6±2.2mm, 4.1±1.6mm, and 3.6±1.6mm for the second, third and fourth metatarsals respectively. Mean time to fusion was 11.4±7.8 weeks and union occurred in 105 toes (99%). The single non-union was asymptomatic at 12 months. Two patients required a subsequent additional DMMO for transfer metatarsalgia. Minor complications were seen in 11 patients (26%). At final follow-up PROMs data was available for 42 cases: mean MOxFQ was 28.8±27.6, mean EQ-5D was 0.789±0.225, mean EQ-VAS was 68.5±20.3, mean VAS-Pain score was 3.1±2.8, and patients were satisfied overall in 40 cases (95%).

CONCLUSIONS

The authors demonstrate excellent radiological and clinical outcomes in the short to medium term with DMMOs and present data on metatarsal shortening achieved with this technique.