3rd Rays Research Articles

Results of Minimally Invasive Distal Metatarsal Osteotomies (Dmmo) Limited to the 2nd and 3rd Rays: About 112 Cases

Category: Lesser Toes Introduction/Purpose: The objective of this study was to evaluate the clinical and radiological results of DMMO limited to the second and third rays in patients suffering from metatarsalgia with lesion of the plantar plate of the second ray associated with a hallux valgus. Our hypothesis was that this gesture allowed an improvement of the clinical and paraclinical symptoms Methods: For this retrospective, single-center, single-operator study, 112 patients (mean age 65.52 years, 91% women, 127 feet) operated between June 2015 and October 2020 were included based on the following criteria: metatarsalgia complicated by lesion of the plantar plate with hallux valgus. Secondary metatarsalgia, congenital malformation, pes cavus, Freiberg's disease, gastrocnemius retraction were excluded The surgery began with DMMOs of the 2nd and 3rd metatarsals, then a minimally invasive chevron osteotomy adjusted the length of the 1st metatarsal in relation to the lateral rays. The position of the toes was guided by a bandage for 2 weeks relayed by a molded orthoplasty for 4 weeks. Support was complete with a rigid flat shoe. At a mean follow-up of 3 years (14-80 months), the AOFAS functional score and radiographic measurements (Maestro criteria, bone consolidation) were evaluated. Results: The clinical improvement was significant with an AOFAS score going from 44.9 to 91.8 (p>0.05)We observed 8.7% of complications: 4 transfer metatarsalgia on the 4th or 5th metatarsal, 1 asymptomatic callus under M4, 1 asymptomatic nonunion of M2, 5 spontaneously resolving delayed consolidation, 1 algodystrophy.The radiographic improvement was significant on our morphotypes which were disharmonious in 92% with M45 hypoplasia in 76% and long M23 in 16%.Indeed, the DMMO limited to the 2nd and 3rd metatarsal allowed a significant reduction in the difference in length between the 3rd and 4th metatarsal (p>0.05)Our 4 cases of transfer metatarsalgia under M4 or under M5 were not explained radiologically by relative length anomaly. Conclusion: Performing DMMO limited to the 2nd and 3rd metatarsals appears to be a reliable solution in the management of metatarsalgia by lesion of the plantar plate associated with hallux valgus, the risk of transfer metatarsalgia was not increased compared to the data of literature.

Normal and five-fingered hand: comparative X-ray morphometry in the post-natal age.

Five-fingered hand (5-FH) with completely developed phalanges is a rare phenotype observed so far only in humans and characterised by three phalanges of the 1st ray. A long-lasting, debated question is if the missing element of the normal hand 1st ray is the metacarpal or the phalanx. In this study, comparative X-rays morphometry of long bones in normal and 5-FH is carried out with the aim to face this question through homology analysis of long bone segments in the transverse and longitudinal line of normal hand and 5-FH. In the normal hand X-rays (n =20) and in a 5-FH X-rays series (n = 9) the relative length of each segment on the ray total length and the index of growth rate (IGR) were assessed. The calculation of the first parameter in normal hand bi-phalangeal thumb was carried out on the 3rd ray total length in the same hand. The parameters of relative length and the proximal/distal growth rate asymmetry in the post-natal period (assessed through the IGR) confirmed in 5-FH the homology of all the five segment on the transverse line. In the normal control hand, the relative length assessment methodology was biased by the missing segment of the thumb, therefore, the reference to the 3rd ray total length in the same hand (instead of the 1st), allowed the homology analysis of the thumb metacarpal and 1st phalanx with the lateral segments (2nd-5th ray) of the same hand. The 5-FH analysis was used to choose the more appropriate reference ray for the normal hand group. The comparative analysis of relative lengths and IGRs in the two groups suggested homology of the (anatomical) 1st metacarpal with the 2nd-5th proximal phalanges in the same hand and that of the (anatomical) 1st proximal phalanx with the 2nd-5th mid phalanges. These data suggest that the missing segment of the normal hand thumb is the metacarpal.

Un cas de syndactylie bilatérale complexe, complète et compliquée

We report the case of a 21-year-old female patient, born with a bilateral hand deformity consisting of syndactyly of the 3rd and 4th rays on each side, without any other associated congenital anomaly. In order to correct the functional and aesthetic discomfort caused by this malformation, she consulted an orthopedic surgeon. A hand X-ray (A, B) was performed to determine the type of syndactyly and any associated bony hand anomalies. It revealed a complex, complete and complicated bilateral syndactyly with, on both the right and the left, a bifidity of the phalanges of the 4th ray forming a synostosis with the 3rd ray. The rest of the bones and joints of the hand are normal. Syndactyly is one of the most common congenital anomalies of the extremities. It is a defect in finger differentiation, defined as a fusion of adjacent fingers. Syndactyly can be seen in the upper and lower extremities, and up to 50% of cases are bilateral. To avoid the morbidity associated with this condition, it must be diagnosed and treated promptly. Syndactyly is described as simple or complex, depending on the presence (complex) or absence (simple) of bony fusion. Complete syndactyly extends to the fingertips with inclusion of the nail folds, while incomplete syndactyly does not extend the full length of the finger. Complicated syndactyly is defined by the presence of interposed accessory phalanges or abnormal bones.

The Positive Association Between Metatarsal Length and Meary’s Angle and Hammertoe Deformity

Category:Lesser Toes; Midfoot/ForefootIntroduction/Purpose:Hammertoe deformities are the most common pathology of the forefoot, accounting for up to 48% of all forefoot operations. There is currently limited evidence documenting differences in foot radiographs and radiographic measurements that may represent a predisposition to developing hammertoe deformity. The purpose of this study was to investigate whether patients with hammertoe deformity demonstrate increased radiographic measurements of first, second, or third metatarsal (MT) lengths as well as Meary’s angle compared to a healthy control group.Methods:Following IRB approval, an institutional radiology database was queried from January 2009-2018 for patients with ICD- 9 and ICD-10 diagnosis codes for hammertoe deformity of the 2nd or 3rd phalange. Control cases were selected using diagnosis codes for acute plantar fascial pain in the same timeframe with medical record review to exclude patients with prior lower extremity injury, surgery or pathology. 234 hammertoe and 110 control patients met inclusion and exclusion criteria. Automated 1:1 case-control matching was performed to control for age, sex and laterality. Following matching, the sample size consisted of 80 patients in each cohort. Proximal to distal end-to-end articular surface radiographic lengths were documented for metatarsals and phalanges of the 1st, 2nd and 3rd rays on anteroposterior radiographs. Lateral talar-first metatarsal (Meary’s) angle was measured using weightbearing sagittal radiographs by calculating the angle formed by lines that bisect the talar neck and anatomic neck of the first metatarsal.Results:A total of 160 patients (80 cases and 80 controls) were included in the study. Mean age was 47.7 years among hammertoe cases and 47.5 years among controls (p=0.92). 54 of 80 cases in each group were female. There was a statistically significant increase in the average Meary’s angle among hammertoe patients (5.23 +- 8.60°) compared to controls (2.15 +- 5.96°) (p<0.01). The average length for the 1st, 2nd and 3rd metatarsals were 65.6, 80.0, and 76.7 mm, respectively for the hammertoe patients and 62.8 mm, 76.0 mm, and 73.5 mm among control cases, respectively. For all three metatarsals, this difference was statistically significant (p<0.01; Table 1). There was no statistically significant difference between lengths of the proximal or distal phalanges.Conclusion:Patients with hammertoe deformity were associated with an increased length on the 1st, 2nd and 3rd metatarsals. Also, these patients demonstrated an increased Meary’s angle creating pes planus deformity. These results illustrate the importance of both medial column instability and long metatarsal length in the development of hammertoe deformity.

Outcomes Following Open Reduction and Internal Fixation in Proximal Phalangeal Fracture with Rotational Malalignment.

Background: The rotational malalignment in proximal phalanx fracture is unacceptable. Authors attempted to describe clinical and radiographic outcomes as well as complications after open reduction and internal fixation with screw only or plate for phalangeal fractures accompanied by rotational malalignment. Methods: Authors conducted a retrospective review of 46 patients who had been treated between Jan. 2010 and Dec. 2016. The average follow-up period was 16.7 months. A total active motion (TAM), Disability of Arm, Shoulder and Hand score (DASH), and tip pinch power between thumb and fractured finger were measured at the final follow-up. Complications were investigated during the follow up. We assessed the amount of rotation by measuring angle between 3rd ray and fractured finger. The measurement was divided into two groups depending on rotation direction, divergent and convergent direction group. Results: Twenty-eight cases were fixed with mini LCP plate, 12 cases with lag screws, and rest 6 cases with combined. All patients showed solid bony union on radiographs on average follow-up of 68 days (range, 41-157 days). Average TAM of the injured finger was 244 degrees and average DASH score was 4.9 at the last follow-up. Tip pinch power was 3.2 kg, which was not significantly different from that of the contralateral side at 3.4 kg (p = 0.21). The preexisting rotational angle was significantly adjusted (overall, 11.1°). Depending on rotation direction, preoperative 21.7° to postoperative 12.1° in 27 patients of convergent group and preoperative -5.0° to postoperative 8.3° in 19 patients of divergent group were achieved. Conclusions: The rotation from proximal phalanx fractures could be corrected with anatomic reduction by open reduction. Our results showed that open reduction and rigid internal fixation after physical examination for acute proximal phalanx fractures accompanied by rotational malalignment could achieve good clinical results.

TL - 18033 - Proximal metatarsal osteotomy with fixation for the treatment of metatarsalgia

Objective: To evaluate the outcomes of proximal metatarsal osteotomies for metatarsal head shortening and/or lifting, assessing pain and function, using the American Orthopedic Foot and Ankle Society (AOFAS) scale. Methods: From November 2002 to November 2014, 29 feet (13 right feet and 16 left feet) of 22 patients (25 women and 4 men) aged 21 to 85 years, with a mean age of 52.8 years, underwent surgery, with a mean follow-up time of 73 months (7 to 150 months). The patients were treated with proximal end metatarsal osteotomies fixed with metallic wires, staples or compression plates with and without grading. Treated comorbidities included hallux valgus deformity, splayfoot, hallux rigidus, pes cavus, hammertoe, crossover toe and plantar plate repair. The patients were evaluated using the AOFAS lesser toes. Results: The AOFAS score improved from 34.5 points (±12.5) preoperatively to 88.9 points (±7.9) postoperatively (p&lt;0.0001). One patient developed a late infection in the foot that was controlled with antibiotics; although the correction of the second toe was partially lost, an acceptable transversal arch was maintained. In all cases except for the infection, no metatarsalgia recurrence or change in the deformity of the corresponding toes occurred. Discussion: Surgical treatment aimed to improve the mechanical distribution of weight and to stabilize the transversal arch, thereby reducing metatarsalgia. The forefoot was stabilized by sufficient shortening and/or lifting to treat metatarsalgia, especially in the 2nd and 3rd rays. We also aimed to achieve complete flexibility of the metatarsophalangeal joints with good alignment. The favorable outcome of this method is comparable to that of the study by Aiello, who achieved good outcomes in 84.9% of 45 feet, whereas our study showed good outcomes in 96% of 29 feet. Conclusion: Proximal metatarsal osteotomies with fixation with metal implants for metatarsalgia treatment showed satisfactory outcomes in 96% of operated cases. We believe that this procedure is effective and safe and has a high rate of patient satisfaction.

Stability of Lisfranc injury fixation in Thiel Cadavers: Is routine fixation of the 1st and 3rd tarsometatarsal joint necessary?

BackgroundThere is debate as to whether a home run screw (medial cuneiform to 2nd metatarsal base) combined with k-wire fixation of the 4th & 5th tarsometatarsal joints is sufficient to stabilise Lisfranc injuries or if fixation of the 1st and 3rd tarsometatarsal joints is also required. Unlike the 2nd, 4th and 5th tarsometatarsal joints, stabilisation of the 1st and 3rd requires either intra-articular screw or an extra-articular plate which risk causing chondrolysis and/or osteoarthritis.The aims of this cadaveric study were to determine if routine fixation of the 1st and 3rd tarsometatarsal joints is necessary and to determine if a distal to proximal home run screw is adequate. MethodsUsing 8 Theil-embalmed specimens, measurements of tarsometatarsal joint dorsal displacement at each ray (1st–5th) and 1st–2nd metatarsal gaping were made during simulated weight bearing with sequential ligamentous injury and stabilisation to determine the contribution of anatomical structures and fixation to stability. ResultsAt baseline, mean dorsal tarsometatarsal joint displacement of the intact specimens during simulated weight bearing (mm) was: 1st: 0.14, 2nd: 0.1, 3rd:0, 4th: 0, 5th: 0.14. The 1st–2nd intermetatarsal gap was 0mm. After transection of the Lisfranc ligament only, there was 1st–2nd intermetatarsal gaping (mean 4.5mm), but no increased dorsal displacement. After additional transection of all the tarsometatarsal joint ligaments, dorsal displacement increased at all joints (1st: 4.5, 2nd: 5.1, 3rd: 3.6, 4th: 2, 5th: 1.3). Stabilisation with the home run screw and 4th and 5th ray k-wires virtually eliminated all displacement. Further transection of the inter-metatarsal ligaments increased mean dorsal displacement of the 3rd ray to 2.5mm. K-wire fixation of the 3rd ray completely eliminated dorsal displacement. ConclusionsThe results of this cadaveric study suggest that stabilising the medial cuneiform to the 2nd metatarsal base combined with stabilisation of the 4th and 5th tarsometatarsal joints with K-wires will stabilise the 1st and 3rd tarsometatarsal joints if the inter-metatarsal ligaments are intact. Thus 3rd TMTJ stability should be checked after stabilising the 2nd and 4/5th. Provided the intermetatarsal ligaments (3rd–4th) are intact, the 3rd ray does not need to be routinely stabilised.

Morphological Study for Identification Improvement of Poeciliidae Family Based on Gonopodium structures and Morphometric analysis

Poeciliidae family consists of small live-bearer fishes with sexual dimorphic. This fishes are widely distributed across Indonesian archipelago, but biological studies on this fish are very limited. This research is aimed to identify the species of Peciliidae fishes which lives in Sari Lake Pasuruan based on gonopodium structures and morphometric analysis. A specific characteristic of the Poeciliidae family is its gonopodium structures which is a modification of 3rd, 4th, and 5th rays of the males anal fin. Each species represented 50 samples male and female from each type we found and measured 26 characters (in mm). Cladogram based on morphometric measurements showed that sample 1 and 2 had 100% similarity, sample 3 had 94% similarity with sample 1 and 2. Sample 4 had 54% similarity with sample 1, 2, and 3. Based on gonopodium structures sample 1 and sample 2 included Xiphophorus hellerii Heckel possess large claw on the terminus of ray 5 hook is small crescent-moon shaped on 3rd ray and lacking of gonopodium palp, sample 3 possesses distal platform with 11 retrosse serrae,and membranous hook so we were able to identify the sample 3 as Poecilia mexicana Steindachner, whilst sample 4 was Poecilia reticulata Peter had a long-pointed comb-like spines on ray 3rd and and has a small hook on the tip of 5p ray.

First Through Third Carpometacarpal Dislocation Variant With Trapezoid Dislocation And Trapezium Fracture

We describe a novel carpometacarpal (CMC) injury pattern of the 1st through 3rd rays with a thumb CMC dislocation, minimally displaced trapezium fracture, trapezoid dislocation and 3rd CMC dislocation. The injury was promptly identified and correctly characterized. Anatomic reduction and internal fixation for an appropriate time period allowed for soft tissue healing and a good short term outcome. We review the pertinent literature to carpometacarpal dislocations and contrast it to the presented case. Thumb CMC dislocation has not been previously reported in association with dislocations of the other rays.

An unusual case of bilateral congenital foot deformities

An 8-year-old boy presented with bilateral congenital foot deformities. His feet showed evidence of duplication, failure of differentiation and central deficiency. His symptomatic left foot had a Y-metatarsal with a normal number of toes due to a combination of duplication (Y-metatarsal) and central deficiency (absent 2nd ray). His asymptomatic right foot had a combination of failure of differentiation (talocalcaneocuboid coalition) and central deficiency (absence of 2nd and 3rd rays and corresponding tarsal bones). These abnormalities resulted in the left foot being wider than the right. The lateral limb of the Y-metatarsal was rubbing on his footwear and causing pain. A good result was obtained at 1 year following excision of the lateral limb of the Y-metatarsal. This case illustrates that Y-metatarsals may occur without polydactly. A good result was obtained in this case with treatment along similar principles as those with polydactly.

Malalignment at the Lisfranc joint: MR features in asymptomatic patients and cadaveric specimens.

To assess the frequency of malalignment in the 1st, 2nd and 3rd tarso-metatarsal joints (Lisfranc joint) in cadaveric specimen and asymptomatic individuals utilizing oblique axial MR images. Four fresh frozen cadaveric feet were dissected in the oblique axial plane at 5 mm slice thickness. Thirty MR studies in 29 patients who had no history of pain, trauma or surgery at the tarso-metatarsal area were included in our study. The 1st to 3rd tarso-metatarsal joints were evaluated on the MR studies and cadaveric slices by two musculoskeletal radiologists for (1) the presence of a medial and/or lateral step-off and (2) articular surface divergence. In the cadaveric dissections there were lateral step-offs in the 1st ( n=3) and in the 2nd ray ( n=3) respectively. No joint incongruity was evidenced. The MR studies in the patients population depicted 28 step-offs (9 medial, 19 lateral) in the 1st ray, 16 (2 medial, 14 lateral) in the 2nd ray and two in the 3rd ray. Joint incongruity was present in the 2nd ray ( n=6) and in the 3rd ray ( n=12). All the above findings were limited to a few images. Isolated joint malalignment with otherwise normal findings (no ligamentous injury, no fracture and no bone marrow edema) might reflect normal anatomic features at the tarso-metatarsal joints and must be interpreted carefully.