Lesser metatarsal V-osteotomy for chronic intractable plantar keratosis. Retrospective analysis of 40 procedures

Strengthening the relationship between intractable plantar keratosis and human papillomavirus

The aim of the study was to determine the presence of human papillomavirus (HPV) in patients with intractable plantar keratosis (IPK) by comparing the histopathological findings of biopsies. A prospective, observational, and concordance study was carried out. Three different specimens were taken from each IPK. A first punch was sent for histopathological examination, and a second punch and a superficial skin scraping were both sent for HPV  polymerase chain reaction (PCR) and type determination. A total of 51 patients were included. From the histopathological examination, it was determined that 35 (68.6%) samples were diagnosed as warts and 16 (31.3%) as keratosis. However, the presence of HPV was confirmed by PCR in 49 (96.1%) and in 42 (82.4%) samples obtained by punch and superficial scraping, respectively. In the 49 PCR-positive samples, the most common HPV types were HPV1, HPV2, HPV27, HPV57, and HPV65, accounting for 81.6% of the samples. In conclusion, this study demonstrates that HPV infection and IPK lesions are very closely related. Although we cannot confirm that HPV is the cause of the development of IPK, the high prevalence of HPV observed in these lesions calls for a change to the procedures for managing IPK.

Orthopaedic and plastic surgery collaboration in resolution of plantar heloma and metatarsalgia using lipofilling: a retrospective evaluation

BACKGROUND

Plantar heloma is a keratotic disorder that can be described as a circumscribed area of thickening with a central core that may penetrate the dermis. Although often considered a minor complaint, longstanding lesions can be debilitating and severely impact on person's quality of life. We present the first retrospective case series at long-term follow-up about the use of plantar lipofilling as a treatment for metatarsalgia caused by plantar heloma.

MATERIALS AND METHODS

Six patients affected by plantar heloma associated to external metatarsalgia underwent plantar lipofilling. The surgical session was performed as an outpatient procedure. Clinical evaluation was performed using the AOFAS lesser metatarsophalangeal-interphalangeal (MTP-IP) score.

RESULTS

Mean AOFAS lesser MTP-IP score improved from a preoperative score of 66.6 ± 3.2 points (range 47-77 points) to a post-operative score of 92.8 ± 2.7 points (range 86-95 points); all patients were satisfied with the outcome at the final follow-up. Post-operative clinical examination at final follow-up showed an increase in thickness of the subcutaneous layer and a decrease of dermal layer thanks to the supporting and trophic action of fat cells.

CONCLUSIONS

Plastic regenerative procedures applicated to a typical foot and ankle surgery field, such as metatarsal overloading, metatarsalgia and forefoot problems, should be encouraged to allow new treatment horizons.

A retrospective audit of lesion excision and rotation skin flap for the treatment of intractable plantar keratosis

AIM

The purpose of this study was to evaluate the treatment of plantar skin lesions by excision and rotation skin flap closure with reference to patient satisfaction; patient reported outcomes and complication rates.

METHOD

A retrospective audit of 54 consecutive patients who had undergone plantar lesion excision with rotation skin flap between May 2011 and November 2015 under the care of experienced consultant podiatric surgeons. A total of 36 patients were included in this study, 16 were lost to follow up, 2 patients were excluded due to non-related pathology. Outcomes were reviewed retrospectively via data extracted from PASCOM-10. This included the MOXFQ and also the PSQ-10 patient satisfaction questionnaire. Data extracted was analysed.

RESULTS

The mean MOXFQ scores improved across the three domains. Walking/standing improved from 68.75 (SD: 17.62) pre-operative to 41.38 (SD: 32.94) post-operative. Pain improved from 63.47 (SD: 19.41) pre-operative to 36.53 (SD: 25.51) post-operative and social interaction improved from 53.88 (SD: 20.33) pre-operative to 29.13 (SD: 26.56) post-operative. Similarly, the PSQ-10 scores have shown positive outcomes where 88.9% out of the cohort felt that their aims of surgery had been met.

CONCLUSION

This audit has demonstrated that the Schrudde flap is an effective and alternative safe surgical procedure for the treatment of intractable plantar keratosis and viral warts.

Computed tomography measurements of the lesser metatarsal heads: Anatomic considerations for surgeons performing distal metatarsal osteotomies

BACKGROUND

The purpose of the current study was to provide a standardized, anatomical description of the lesser metatarsals to assist surgeons when planning distal metatarsal surgery and fixation.

METHODS

Eighty CT scans were included for assessment, based on a priori power analysis. Patient age was a mean 52.7±16.6 years (24-83). Metatarsals two through five were assessed in all patients. Three independent observers completed measurements for all metatarsals. Three measurements were made on all metatarsals, including a vertical height and metatarsal head and neck measurements. Statistical analysis was performed (alpha value 0.05). Inter-observer reliability was assessed for all measurements and intra-class correlation (ICC) reported.

RESULTS

A sequential decrease in metatarsal measurements was noted from the second to the fifth metatarsal. A mean vertical height measurement of 16.1±1.4mm (range, 13.4-19.4) was recorded for the second metatarsal, decreasing 13.0±1.1mm (range, 10.3-16.1) for fifth. There were no significant differences in metatarsal measurements based on gender in our study. Similar patient and metatarsal variability was seen head and neck measurements. Intraclass correlation coefficients (ICC) for metatarsal measurements were greater than 0.9 [95% CI; 0.936-0.991] correlation, denoting an 'excellent' interobserver reliability.

CONCLUSION

This study provides a baseline anatomical description of the distal metatarsals. These findings, including the variation found between patients and between metatarsal two through five, are relevant to surgeons planning and performing distal metatarsal osteotomies.

Lesser Metatarsal Osteotomy

Central metatarsal osteotomy is an effective approach in alleviating pain oriented to the forefoot. The procedures individually are straightforward in the isolated scenario. A working knowledge of the specific and unique pathobiomechanics is imperative when considering surgical intervention for the given pathologic scenario. Treating only the pain focus generally underserves the pathology and does not address the high point of the deformity. The surgeon must be cognizant of the complication potpourri, prepare the patient expectations, and engage a level of proactivity against sequelae to ensure the best possible and most predictable outcome.

Revisiting the tailor's bunion and adductovarus deformity of the fifth digit

Correction of the fifth digit deformity and Tailor's Bunion can be rewarding as well as challenging for a foot and ankle surgeon. Immense care should be taken when performing these reconstructive surgical procedure, especially to avoid and minimize complication rates and mainly to prevent neurovascular damage. Appropriate surgical procedure selection for the fifth digit deformity and Tailor's Bunion is necessary in order to obtain a long term predictable outcome.

Metatarsalgia: proximal metatarsal osteotomies

Metatarsalgia is a blanket term to describe pain in the forefoot that may have many different etiologies and contributory factors. A careful history, examination, and appropriate imaging are required to make an accurate diagnosis and treat the patient appropriately. Metatarsalgia is a common condition and is more common in women. Many nonsurgical treatments can be implemented as a first line but if these fail then surgery may be undertaken. There are several different lesser metatarsal osteotomies described with little published evidence to recommend one over another, leaving the decision as to which one to use largely to surgeon choice. The surgeon, however, must decide, by using a combination of clinical examination and imaging, whether the desired effect of the osteotomy is to shorten or elevate the metatarsal head or both. Whichever method is employed it is important to maintain or restore the metatarsal cascade to keep even pressure under the lesser metatarsal heads and prevent transfer lesions. Proximal osteotomies are more powerful than distal ones but often that can mean that they are more technically demanding. Many early descriptions of osteotomy techniques did not include any fixation but the results in terms of union and relief of symptoms as well as the prevention of transfer pain appear to be better with fixation. More research is required comparing the different osteotomy techniques to ascertain which can most reliably resolve patients’ symptoms with the lowest complication rate.

Complications and salvage of elective central metatarsal osteotomies

In order to provide proper treatment intervention, the foot and ankle surgeon must develop a further understanding of the pathoanatomy and pathomechanics leading to specific surgical complications of central metatarsal osteotomies. In addition to providing the authors' experiences and potential solutions with regard to these complications, a clear definition of the progression of the complication course is presented. The specific complications of floating toe deformity, metatarsalphalangeal joint stiffness, recurrent metatarsalgia, transfer lesions, malunions, and nonunions are discussed.

Resolution of metatarsalgia following oblique osteotomy

Metatarsalgia of the central ray is a major surgical challenge. Without precise correction, transfer lesions may occur at an adjacent metatarsal or patients may have inadequate pain relief. Current surgical treatment strategies do not facilitate precise positioning in different planes, resulting in disappointing outcomes. To achieve better outcomes we used an oblique sliding osteotomy to facilitate precise correction. We hypothesized the procedure would reduce pain in patients with prominent second and/or third metatarsal heads, with few complications. We retrospectively reviewed 32 consecutive patients with 42 osteotomies of the lesser metatarsal bones. The mean and median ages at the time of surgery were 49 and 54 years, respectively, with a minimum followup of 26 months. Thirty-one patients (97%) had relief of plantar pain. The mean American Orthopaedic Foot and Ankle Society score was 82.4 points. We identified no transfer lesions. The median time to radiographic union was 10 weeks. Although time to bony union can be extended, the oblique sliding osteotomy facilitates intraoperative adjustment to provide the precise positioning critical to eliminating plantar pain.

Plantar pressure and load in cadaver feet after a Weil or chevron osteotomy

BACKGROUND

Since metatarsal osteotomy was first used to treat metatarsalgia in the early twentieth century, many techniques have been described to accomplish the basic aim of reduction of load transmission through the operated metatarsal and reduction of localized high pressure on the plantar surface of the metatarsal. Our study examined two popular distal metatarsal neck osteotomies used for the relief of central metatarsalgia and the biomechanical changes that result from their use in a cadaver forefoot model.

METHODS

After applying 445 N (100 lbs) of axially directed force, we measured plantar pressure using the TekScan HR Mat (TekScan, Inc., South Boston, MA) in twelve paired, thawed, fresh-frozen intact cadaver legs, then after either a Weil or chevron osteotomy of the second metatarsal and finally after the addition of the same osteotomy of the third metatarsal.

RESULTS

Load in the forefoot was not significantly affected by the Weil osteotomy. A significant increase in load was produced in the first metatarsal region, and significant decreases in load were produced beneath the operated metatarsal heads after the chevron osteotomy. Average pressure in the contact area of the forefoot showed similar trends; however, load and pressure changes occurred independently, owing to the changes in contact area produced by the osteotomies. No significant changes were observed in the nonoperated metatarsal regions.

CONCLUSIONS

In this model, the chevron osteotomy more effectively reduced load and plantar pressure in the operated metatarsal regions; however, increases in load and pressure were observed in the first metatarsal region. The increase in pressure without a change in load in region 3 (third metatarsal) after a Weil osteotomy of the third metatarsal was attributed to the creation of a plantar prominence. This study did not show a reduction in load transmission as a result of the Weil osteotomy, which contradicts the proposed mechanism of clinical benefit. An intact first ray likely prevents transfer of load or pressure to adjacent lesser metatarsals with chevron osteotomy.

The arterial supply of the lesser metatarsal heads: a vascular injection study in human cadavers

The possibility of avascular changes of the metatarsal heads following forefoot surgery has been previously documented. The aim of this study was to investigate the arterial supply of the lesser metatarsal heads with regard to osteotomies of these bones. We used epoxy resin injections and a modified Spalteholz technique in human cadaveric specimens to demonstrate the intraosseous and extraosseous blood supply of the lesser metatarsals. The metatarsal heads had two arterial sources: 1. The dorsal metatarsal arteries, which arose from the dorsalis pedis artery, and 2. The plantar metatarsal arteries, which are branches of the posterior tibial artery. These two vessels typically anastomosed at two sites about the metatarsal heads, forming a vascular ring and provided an extensive extraosseous arterial network around the metatarsal heads. Small arterial branches of this network run distally on the metatarsal cortex to enter the bone of the metatarsal head. The nutrient arteries traversed the cortex of the metaphysis close to the capsular and ligamentous insertions to provide multiple branches for the supply of the subchondral bone. Extensive capsular stripping during metatarsal head osteotomies results in damage to the medial and lateral head vessels.

Lesser metatarsal osteotomies. A biomechanical approach to metatarsalgia

As with most other orthopedic conditions, a firm understanding of the normal and pathologic biomechanics of the lesser metatarsals is essential when contemplating treatment of metatarsalgia. Despite its prevalence, metatarsalgia remains a technically demanding surgical challenge. Some of the difficulty with treatment of this problem arises because of some of the controversies discussed previously. Many lesser metatarsal osteotomies have been described, and their success depends on many factors. Alleviating the correct amount of pressure underneath the metatarsal head without adversely affecting the biomechanics of the region demands an exacting osteotomy that is stable and readily heals. Much of the research done to date has not proved which procedure can achieve these goals reproducibly for patients. It is hoped that future investigations will guide treatment choices and allow patients to obtain relief from this difficult problem with greater success.

Proximal shortening lesser metatarsal osteotomy: a mathematical-geometric basis

Reconstruction and restoration of the lesser metatarsal parabola after an iatrogenic complication of a lesser metatarsal osteotomy provides a difficult surgical dilemma for the foot and ankle surgeon. This study's purpose was to determine if a formula could be developed, through a geometric and mathematical basis, for the proximal shortening lesser metatarsal osteotomy to aid the surgeon in determining the amount of bone needed to be resected to correct the deformity. This study was divided into three parts. In part I, 15 lesser metatarsals (metatarsals 2, 3, and 4) harvested from fresh frozen cadavers had shortening proximal osteotomies performed. This osteotomy removes a cylindrical piece of bone that is perpendicular to the metatarsal shaft from the proximal aspect of the lesser metatarsal to create axial shortening of the metatarsal and changes the relationship of the metatarsal head to the weightbearing surface. These metatarsals had five radio-opaque markers placed into them and were radiographed pre- and postosteotomy. These markers created a pre- and postgeometric graphic plotting for the changes in length, height, and dorsiflexion. Computer graphing was then utilized to analyze changes in height, length, and dorsiflexion of each metatarsal. Formulas were created from these plottings to determine the actual change in height, length, and dorsiflexion for a set amount of bone removed. The formulas created from these data were: Length: Actual change = Bone removed *0.95; Height: Actual change = Bone removed *0.54; and Dorsiflexion: Actual change = Bone removed *0.44 mm/deg. In part II of study, 15 identical saw bone lesser metatarsals were used to verify the formulas, by taking out the amount of bone needed for 0.5-mm increment change, starting at 1.0 mm and increasing to 8.0 mm. Techniques used were identical to part one. Part III was performed to demonstrate that the formula would be reproducible for height when there is a difference in the angulation of the metatarsal. Fifteen identical sawbones where plotted in plaster at declinations ranging from 8 degrees to 42 degrees. Then the osteotomy was performed removing 4.0 mm of sawbone from each specimen using the same technique as parts I and II. All parts and the formulas were statistically analyzed using a bivariate regression model, which showed that the formulas were valid for length, height, and dorsiflexion with a 95% confidence. With these experimental models, the authors found reproducible formulas that hopefully could aid the surgeon in determining the amount of bone they needed to resect to effect correction of this difficult reconstruction.