Metatarsal Research Articles

Surgical management of metatarsal fracture using wire suture in a sheep: A case report

Background: The most frequent orthopedic condition that prevents animals from moving normally is a long-bone fracture. The diagnosis and surgical treatment of closed metatarsal fracture in sheep are the main goals of this study. Materials and Methods: A three-month-old female sheep was presented with a history of the left metatarsal bone losing its function, pain at the fracture site, aberrant motion in the affected leg, and fluid or exudate flowing from the fracture site. While radiographs indicated an oblique metatarsal fracture of the left hind limb, palpation of the left metatarsal bone revealed discomfort and fracture fragments. Following internal stabilization with cerclage wire suture, the fracture was treated. Surgery was carried out following the proper immobilization, aseptic procedure, and anesthetic protocol (atropine 0.04 mg/kg BW intramuscularly, five minutes later: xylazine 0.06 mg/kg BW intravenously). Results: The sheep was released from the hospital after the procedure bearing weight on the limb effectively and without any issues. A successful clinical outcome was obtained after surgical alteration. Conclusions: Open fractures necessitate swift, aggressive debridement, stability of the fracture, and early soft tissue restoration. The only practical method for managing fractures may be early surgical treatment and post-operative care.

Biomechanical Comparison of Cannulated Screw Osteosynthesis With Tension-Band Wiring for Proximal Fractures of the Fifth Metatarsal (Jones Fracture)

Jones fractures, which lie at the junction of the diaphysis to the metaphysis of the fifth metatarsal, are a well-described clinical issue. There are various surgical approaches, including the commonly performed cannulated screw osteosyntheses, and the less frequently used tension-band approach. The aim is to compare the biomechanical stability of these osteosyntheses. We performed an osteotomy on 16 fresh frozen fifth metatarsal bones from body donors representing a Jones fracture. The fractures were treated pairwise with screw osteosynthesis or tension-band wiring. This was followed by cyclic axial bending until osteosynthesis failure. Stability under axial bending force was higher in the screw osteosynthesis (mean: 70.0 ± 66.5 N) compared to the tension-band wiring (mean: 35.7 ± 23.3 N) group although not reaching statistical significance (p = .116). The study shows no statistically significant difference in biomechanical stability under axial loading between screw osteosynthesis and tension band wiring. Based on the data obtained, no differences can be observed from a biomechanical point of view. The study supports the established method of treating Jones fractures primarily with screw osteosynthesis. In addition, the data suggest that tension band wiring may be a good alternative osteosynthesis, for example, after failed casting treatment or failure of primary osteosynthesis.

Difficulties in the Treatment of Diabetic Foot and Research Progress of Combination of Traditional Chinese and Western Medicine.

A diabetic foot is any disorder directly attributable to peripheral arterial disease (PAD) and/or the sensory neuropathies influencing the diabetic foot; it is a long-term (or “chronic”) complication of diabetes. Generally, it is a permanent (or “chronic”) comorbidity of diabetes. The swallowing of peripheral neuropathy and peripheral vascular disease leads to damage to the soft tissue, bone, and joint system of the foot. In addition, diabetic feet are also susceptible to infection, which can lead to lameness and even amputation. The management of the diabetic foot can be both challenging and chronic; it may comprise orthoses, surgery, antibacterial medication, and topical dressings. Traditional Chinese medicine (TCM) has a variety of methods for the treatment of diabetic foot with obvious advantages, which can be divided into internal treatment and external treatment of TCM. These treatments include external foot bath, fumigation and washing stains, internal administration of traditional Chinese medicine, syndrome differentiation and staging treatment, empirical prescription, self-made prescription, internal use of proprietary Chinese medicine, massage, acupuncture, and paste powder application, which have significant value in the prevention and treatment of diabetic foot. Some studies have shown that modern medicine combined with herbal therapy can significantly improve the prognosis of diabetic foot. Therefore, this study summarized the difficulties in the therapeutic approaches to diabetic foot and the recent research progress in combining Chinese and Western medicine in the treatment of diabetic foot.

Blocking circadian clock factor Rev-erbα inhibits growth plate chondrogenesis via up-regulating MAPK-ERK1/2 pathway

ABSTRACT Emerging evidence indicated circadian clock gene Rev-erbα was involved in cartilage metabolism, however the contribution of Rev-erbα to growth plate chondrogenesis remains unknown. Here, we found that Rev-erbα exhibited the spatiotemporal expression model in growth plate. Moreover, Rev-erbα antagonist SR8278 inhibited longitudinal elongation of metatarsal bone ex vivo. And morphological analysis exhibited SR8278 led to the reduced height of growth plate and hypertrophic zone. Furthermore, blocking Rev-erbα suppressed the proliferation and hypertrophic differentiation of chondrocytes in growth plate. Similarly, knock-down Rev-erbα inhibited the proliferation and differentiation of primary chondrocytes in vitro. The mechanistic study indicated that knock-down Rev-erbα up-regulated MAPK-ERK1/2 pathway in chondrocytes. However, restraint of MAPK-ERK1/2 pathway alleviated partially SR8278-inhibited longitudinal elongation of metatarsal bone and growth plate development. Therefore, our results provide evidence of the vital role of Rev-erbα on growth plate chondrogenesis.

Complications in the surgical treatment of adolescent hallux valgus

Objective: Evaluation the degree of complications in the surgical treatment of adolescent hallux valgus Material and method: The study examines 47 cases of surgically treated children with adolescent hallux valgus with a mean age of 14.3 years. Most of the patients were female - 93.75%. and the most affected is the right foot - 51.21%. For diagnosis and follow-up of the treatment result, X-ray methods were used with angular imaging measurements - hallux valgus angle (HVA) and intrametatarsal angle (IMA).
 Results: The mean follow-up period was 15.8 m. The mean preoperative angle of hallux valgus was 30.19 o and the mean preoperative intrametatarsal angle was 11.44o. In the final results we report a loss of correction of HVA on average to - 20.46 o (min 6.8 o max 38.2 o) and preservation of IM with an average value of 7.35 o. The Clavien Dindo classification was used to account of the postoperative complications. The recurrence rate reported at 10 months postoperatively were 15 cases or 31.91%. The following postoperative complications were reported for the follow-up period: avascular necrosis of the metatarsal head 1 year postoperatively and intraoperative fracture of the first metatarsal bone.
 Conclusions: Despite the many described surgical techniques, there are still no long-term indicative results for successfully used surgery. After processing our data and compare it with those of the world literature, we come to the conclusion that the rate of possible recurrence in the surgical treatment of AHV is high. The closure of the growth zone is confirmed as one of the criteria for the outcome of the treatment and the degree of postoperative recurrence of the deformity.

Epiphysiodesis of the first ray as a method of treat-ment of adolescent hallux valgus

Presentation of short-term results from the application of epiphysiodesis of the first ray as a method of treatment of adolescent hallux valgus.
 Material and method: The operative technique was introduced in USHATO in January 2018 like a operative procedure for treatment of mild and moderate deformity of adolescent hallux valgus (AHV). The technique includes percutaneous access to the growth zones in the area of ​​the first metatarsal bone and proximal phalanx and partial epiphysiodesis of the growth complex. The study presents 12 cases in 9 children with a mean age of 10.1 years (min. 5 years, max. 13 years). Most of the patients were female - 77.78%. According to the three-dimensional Stantrock classification and the HV severity classification, the twelve cases fell into group II-A and moderate severity. Three angular parameters hallux valgus angle(HVA), intra-metatarsal angle (IMA), distal-metatarsal articulation angle (DMAA), were used to monitor the results, and the measurements were performed preoperatively, intraoperatively and postoperatively.
 The American Orthopaedic Foot and Ankle Society (AOFAS), was used to report clinical outcomes.
 Results: Patients were followed up for a mean period of 17.58 months. For this period we do not established postoperative recurrences, and all cases remain in the same group according Stantrock classification and the HV severity classification.
 In the three monitored radiographic parameters we report clinical, but not statistical improvement: HVA by an average of 1.19°, IMA by an average of 0.55° and loss of correction in DMAA by 0.9°. For the follow-up period, we report a statistical improvement in the clinical parameters reported on the AOFAS scale (p <0.4).

Prevalence of flatfoot among young Korean males and the correlation among flatfoot angles measured in weight-bearing lateral radiographs.

Flatfoot causes significant fatigue and pain while walking, and even asymptomatic flatfoot may increase the risk of metatarsal stress fracture during long-distance walking. While most studies have used physical examination or plantar footprints to diagnose flatfoot, a weight-bearing radiograph of the foot provides more objective data. However, data on the prevalence of flatfoot in Asian populations gathered in a nationwide cohort of a specific age group is lacking. We examined the prevalence of flatfoot among 19-year-old male Korean army recruits using a weight-bearing lateral radiograph and evaluated the correlation among flatfoot angles. A total of 560,141 19-year-old Korean males were examined at the regional Military Manpower Administration offices between April 2018 and April 2020. Weight-bearing lateral radiographs of the foot were obtained using an X-ray system while the subjects were standing on a table with their feet in a neutral position. Based on these radiographs, military orthopedic surgeons and radiologists measured the talo-first metatarsal angle (TMA) and calcaneal pitch angle (CPA) for flatfoot diagnosis. Mild flatfoot was diagnosed when the TMA ranged from 6 to 15° or the CPA was <17°, and moderate-to-severe flatfoot was diagnosed when the TMA was 15° or greater or the CPA was <10°. Pearson correlation coefficients and scatter plot matrix were used to evaluate the correlation among the flatfoot angles. Finally, we evaluated the relationship between body mass index (BMI) and flatfoot angles and compared the BMI in subjects with or without self-checked foot deformities including flatfoot and pes cavus. Of the 560,141 subjects, 16,102 (2.9%) were diagnosed as flatfoot, and 5265 (0.9%) were diagnosed with moderate-to-severe flatfoot. The coefficients between TMA and CPA ranged from 0.342 to 0.449 (all P values < 0.001), and those between the 2 sides of TMA and CPA were 0.709 and 0.746 (all P values < 0.001), respectively. BMI had a significant correlation with both TMA and CPA in subjects with flatfoot, and those with self-checked foot deformities had a significantly higher BMI than the group without foot deformities. The prevalence of total flatfoot and moderate-to-severe flatfoot in 19-year-old Korean males based on a weight-bearing lateral radiograph was 2.9% and 0.9%, respectively. The correlation coefficients between TMAs and CPAs showed a low degree of positive correlation. Higher BMI was associated with the likelihood of the presence of flatfoot.

Portable dynamic ultrasonography is a useful tool for the evaluation of suspected syndesmotic instability: a cadaveric study

PurposePortable ultrasonography (P-US) is increasingly used to diagnose syndesmotic instability. The aim of this study was to evaluate syndesmotic instability by measuring the distal tibiofibular clear space (TFCS) in a cadaveric model using P-US with progressive stages of syndesmotic ligamentous transection under external rotation stress.MethodsTen fresh lower leg cadaveric specimens amputated above the proximal tibiofibular joint were used. Using P-US, the TFCS was evaluated in the intact stage and after progressive sectioning of the (1) anterior–inferior tibiofibular ligament (AITFL), (2) interosseous ligament (IOL), and (3) posterior–inferior tibiofibular ligament (PITFL). The TFCS was measured in both the unstressed (0 Nm) state and with 4.5, 6.0, 7.5, and 9.0 Nm of external rotation stress using a bone hook placed on the first metatarsal bone at each stage of ligamentous transection stage using both P-US and fluoroscopy.ResultsWhen assessed with P-US, partial syndesmotic injury encompassing the AITFL and IOL resulted in significant TFCS widening at 4.5 Nm of external rotation torque when compared to intact state with a TFCS-opening of 2.6 ± 2 mm, p = 0.01. In contrast, no significant differences in TFCS were detected using fluoroscopy. Only a moderate correlation was found between P-US and fluoroscopy.ConclusionP-US is a useful tool in diagnosing syndesmotic instability during external rotation stress examination. TFCS-opening increased as additional ligaments of the syndesmosis were transected, and application of 4.5 Nm torque was sufficient to detect a difference of 2.6 mm after the IOL cut.

The Management of Complex Regional Pain Syndrome-associated Foot Pain using a Poron Insole, a Sponge Upper Padding, and a Post-operative Shoe: A Case Report

Background: Pain from complex regional pain syndrome (CRPS) is frequently refractory to various treatment methods. Here, we present a case wherein foot pain from CRPS I was managed by applying an insole made from poron (a soft polyurethane foam and highly absorbent material for shock reduction), a sponge upper padding, and a post-operative shoe. Case Presentation: A 47-year-old female patient with CRPS I on her left foot complained of pain for a few months, which was aggravated while standing and walking [numeric rating scale (NRS): 8]. She had a history of a linear fracture in the distal portion of the left 1st metatarsal bone 5 months ago, and the pain from CRPS started 2 months after the fracture. We believed that the aggravated pain during standing and walking was allodynia. We utilized a poron insole, a sponge upper padding, and a post-operative shoe to reduce the pressure and friction loading on her left foot. 1 month after this intervention, the patients’ pain during standing and walking was found to have reduced from NRS 8 to NRS 3. At her 3- and 6-month follow-ups, the degree of pain was sustained at NRS 3. Conclusion: We believe that the reduction of allodynia using materials, which can absorb mechanical pressure and friction of the foot, can help manage pain from CRPS.

Location-specific cutaneous electrical stimulation of the footsole modulates corticospinal excitability to the plantarflexors and dorsiflexors during standing.

Non‐noxious electrical stimulation to distinct locations of the foot sole evokes location‐specific cutaneous reflex responses in lower limb muscles. These reflexes occur at latencies that may enable them to be mediated via a transcortical pathway. Corticospinal excitability to the plantarflexors and dorsiflexors was measured in 16 participants using motor evoked potentials (MEPs). Spinal excitability was measured in eight of the original participants using cervicomedullary motor evoked potentials (CMEPs). Measurements were collected with and without preceding cutaneous stimulus to either the heel (HEEL) or metatarsal (MET) locations of the foot sole, and evoked potentials were elicited to coincide with the arrival of the cutaneous volley at either the motor cortex or spinal cord. Plantarflexor MEPs and CMEPs were facilitated with cutaneous stimulation to the HEEL for MEPs (soleus p = 0.04, medial gastrocnemius (MG) p = 0.017) and CMEPs (soleus p = 0.047 and MG p = 0.015), but they were unchanged following MET stimulation for MEPs or CMEPs. Dorsiflexor MEPs were unchanged with cutaneous stimulation at either location, but dorsiflexor CMEPs increased with cutaneous stimulation (p = 0.05). In general, the increase in CMEP amplitudes was larger than the increase in MEP amplitudes, indicating that an increase in spinal excitability likely explains most of the increase in corticospinal excitability. The larger change observed in the CMEP also indicates that excitability from supraspinal sources likely decreased, which could be due to a net change in the excitability of intracortical circuits. This study provides evidence that cutaneous reflexes from foot sole skin are likely influenced by a transcortical pathway.

Bone-microarchitecture and bone-strength in a sample of adults with hypophosphatasia and a matched reference population assessed by HR-pQCT and impact microindentation.

Hypophosphatasia (HPP) is an autosomal recessive or dominate disease affecting bone mineralization, and adults with HPP are in risk to develop metatarsal stress fractures and femoral pseudofractures. Given to the scarce data on the bone quality and its association to the fracture risk in adults with HPP, this study aimed to evaluate bone turnover, bone strength and structure in adults with HPP. In this cross-sectional study, we included 14 adults with genetically verified HPP and 14 sex-, age-, BMI-, and menopausal status-matched reference individuals. We analyzed bone turnover markers, and measured bone material strength index (BMSi) by impact microindentation. Bone geometry, volumetric density and bone microarchitecture as well as failure load at the distal radius and tibia were evaluated using a second-generation high-resolution peripheral quantitative computed tomography system. Bone turnover markers did not differ between patients with HPP and reference individuals. BMSi did not differ between the groups (67.90 [63.75-76.00] vs 65.45 [58.43-69.55], p=0.149). Parameters of bone geometry and volumetric density did not differ between adults with HPP and the reference group. Patients with HPP had a tendency toward higher trabecular separation (0.664 [0.613-0.724] mm vs 0.620 [0.578-0.659] mm, p=0.054) and inhomogeneity of trabecular network (0.253 [0.235-0.283] mm vs 0.229 [0.208-0.252] mm, p=0.056) as well as lower trabecular bone volume fraction (18.8 [16.4-22.7] % vs 22.8 [20.6-24.7] %, p=0.054) at the distal radius. In addition, compound heterozygous adults with HPP had a significantly higher cortical porosity at the distal radius than reference individuals (1.5 [0.9-2.2] % vs 0.7 [0.6-0.7] %, p=0.041). BMSi is not reduced in adults with HPP. Increased cortical porosity may contribute to the occurrence of femoral pseudofractures in compound heterozygous adults with HPP. However, further studies investigating larger cohorts of adults with HPP using methods of bone histomorphometry are recommended to adequately assess the bone quality in adults with HPP.

On-Top Plasty at the Level of the Metatarsal Neck for Treatment of Polydactyly

Polydactyly is a common deformity of the limbs, and excision of the extra digit has shown good results in the vast majority of patients. However, this treatment approach may not suitable for all cases of polydactyly. Some complex surgical procedures are required to treat rare forms of polydactyly and achieve satisfactory correction. Here, we report the use of on-top plasty technique for treating polydactyly between the 4th and 5th metatarsals with concomitant angulation of the 5th metatarsophalangeal joint. We performed the first osteotomy at the neck of metatarsal bone by “grafting” the distal polydactyly with the normal axis to the 5th metatarsal bone. Excision of the extra toe was accompanied by simultaneous restoration of the 5th toe axis and decrease in the width of the forefoot. Finally, both appearance and function could be improved. With this novel method, the complete osteoarticular structure and weight-bearing structure of foot were well-reconstructed. Based on the findings, we recommend that for the surgery of polydactyly, the beneficial parts should be preserved for reconstruction, and the tailored and personalized approach could be adopted.

Aggressive giant cell tumour of the talus: a rare case report and challenges faced during its management

&lt;p&gt;Giant cell tumour (GCT) of the bone is a locally aggressive benign tumour that commonly occurs in the epiphyseal ends of long bones. Its occurrence in the small bones of the foot like the talus is rare. In this case report we described a case of aggressive GCT of the talus (Campanacci grade 3) in a twenty-one years old male diagnosed by the presence of a well-defined osteolytic lesion seen involving the talar body with cortical breach and soft tissue extension confirmed to be a GCT by closed needle biopsy. The patient was managed surgically by excision of the tumour mass in-toto along with the talus followed by tibio-calcaneal fusion using free fibular strut graft and Ilizarov frame. At 3 months follow up no evidence of fusion was seen and therefore secondary augmentation with a cortico-cancellous graft from the iliac crest was done to aid fusion and Ilizarov fixator was removed 6 months after the surgery. The patient at one year follow up had shown no signs of recurrence of the tumour and has a pain free, stable fused tibiocalcaneal joint with a bipedal unassisted gait. Our case report found excision of talus combined with tibio-calcaneal fusion using free fibular strut graft along with cortico cancellous iliac bone graft to have a good outcome in terms of aiding tibio-calcaneal arthrodesis and thereby providing pain relief and providing a stable foot to the patient.&lt;/p&gt;

Time-Dependent Collagen Fibered Structure in the Early Distraction Callus: Imaging Characterization and Mathematical Modeling

Collagen is a ubiquitous protein present in regenerating bone tissues that experiences multiple biological phenomena during distraction osteogenesis until the deposition of phosphate crystals. This work combines fluorescence techniques and mathematical modeling to shed light on the mechano-structural processes behind the maturation and accommodation-to-mineralization of the callus tissue. Ovine metatarsal bone calluses were analyzed through confocal images at different stages of the early distraction osteogenesis process, quantifying the fiber orientation distribution and mean intensity as fiber density measure. Likewise, a mathematical model based on the experimental data was defined to micromechanically characterize the apparent stiffening of the tissue within the distracted callus. A reorganization of the fibers around the distraction axis and increased fiber density were found as the bone fragments were gradually separated. Given the degree of significance between the mathematical model and previous in vivo data, reorganization, densification, and bundle maturation phenomena seem to explain the apparent mechanical maturation observed in the tissue theoretically.

Effects of badminton insole design on stress distribution, displacement and bone rotation of ankle joint during single-leg landing: a finite element analysis

ABSTRACT Previous research has reported that up to 92% of injuries amongst badminton players consist of lower limb, whereby 35% of foot fractures occurred at the metatarsal bone. In sports, insoles are widely used to increase athletes’ performance and prevent many injuries. However, there is still a lack of badminton insole analysis and improvements. Therefore, this study aimed to biomechanically analyse three different insole designs. A validated and converged three-dimensional (3D) finite element model of ankle–foot complex was developed, which consisted of the skin, talus, calcaneus, navicular, three cuneiform, cuboid, five metatarsals and five phalanges. Three existing insoles from the market, (1) Yonex Active Pro Truactive, (2) Victor VT-XD 8 and (3) Li-Ning L6200LA, were scanned using a 3D scanner. For the analysis, single-leg landing was simulated. On the superior surface of the skin, 2.57 times of the bodyweight was axially applied, and the inferior surface of the outsole was fixed. The results showed that Insole 3 was the most optimum design to reduce peak stress on the metatarsals (3.807 MPa). In conclusion, the optimum design of Insole 3, based on the finite element analysis, could be a justification of athletes’ choices to prevent injury and other complications.

The Role of the Shortened Proximal Phalanx in the Setting of Brachymetatarsia

Brachymetatarsia is a condition in which a metatarsal bone does not grow out to full length. This is caused by premature physeal closure. The proximal phalanx associated with the shortened metatarsal helps achieve the natural parabola of the foot. A hypoplastic proximal phalanx is a common finding in patients with brachymetatarsia. The goal of this study was to determine the length of the proximal phalanx in the setting of brachymetatarsia, and how much the shortening is attributed to the clinically smaller toe. We performed a retrospective study to evaluate the length of the proximal phalanx in the shortened ray. After the metatarsal was brought out to the desired length of correction, the proximal phalanx was measured on radiographs. Ninety-seven feet with congenital brachymetatarsia were reviewed in a cohort of 66 patients who underwent surgical correction between January 2005 and February 2020 at a single institution. The group was comprised of 61 females and 5 males, with a mean age of 27.5 years. The average length of the proximal phalanx associated with the affected metatarsal was noted to be 18.9 ± 3.83 mm for males and 15.6 ± 4.02 mm for females. Our results indicate the shortened proximal phalanx is 5 mm shorter when compared to normal population and is a contributing factor to the shortened clinical appearance of the digit in brachymetatarsia. Treating surgeons should be aware of this to better educate patients on the influence of the digit on the overall shortening seen in cases of brachymetatarsia.

Болезнь Фрайберга-Келера: клиника, диагностика, лечение (обзор литературы)

Introduction The paper deals with the main aspects of osteochondropathy of the heads of the II–V (small) metatarsal bones. The relevance of the problem of treating patients with Freiberg-Kohler disease can be explained by high incidence and poor results of traditional methods of its management. Objective The aim of this work was an attempt to generalize the available data and improve the understanding of approaches to the treatment of osteochondropathy of the heads of the II–V metatarsals. Materials and methods The publications obtained in various information systems (PubMed, eLibrary.ru, Google Scholar) were reviewed. Results Issues of history, etiology, pathogenesis, systematization and diagnosis of this disease were highlighted. The analysis of existing methods of treatment was carried out. Their advantages and disadvantages were assessed. Conclusion Despite more than a century of studies on Freiberg-Kohler disease, the available literature is scarce. Most works are case reports or series of cases describing small samples. This fact significantly reduces the scientific value. Thus, improving the methods of diagnosis and treatment of patients with this disease based on the foundations of evidence-based medicine is a task of current traumatology and orthopedics.

Morphological variability of the fibularis tertius tendon in human foetuses.

In adults, the fibularis tertius (FT) demonstrates great morphological variation. The present study classifies the types of FT insertion in human foetuses and compares their prevalence to the prevailing classification among adults. Fifty spontaneously-aborted human foetuses (19 male, 31 female, 100 upper limbs in total) aged 18-38 weeks of gestation at death were examined. The foetuses were obtained from spontaneous abortion after parental consent. The study was performed in accordance with the legal procedures in force in Poland and with the Body Donation Programme for both adults and foetuses. The most common type of FT found was type VI (32%), characterised by a bifurcated distal attachment: a main tendon inserting onto the base of the fourth metatarsal bone, and accessory bands inserting onto the fourth interosseous space. Five other types were observed: type IV (20%), with a single tendon inserting distally to the fascia covering the fourth interosseous space; type I (18%), with a single tendon inserting distally onto the shaft of the fifth metatarsal bone; type V (14%), with a bifurcated arrangement comprising a main tendon characterised by a very wide insertion onto the base of the fifth metatarsal bone and an accessory band inserting onto the base of the fourth metatarsal bone; and type III (12%) with a single tendon inserting distally onto the shaft of the fourth metatarsal bone and fascia covering the fourth interosseous space. Finally, type II (4%) was characterised by a single tendon inserting onto the base of the fifth metatarsal bone via a very wide distal insertion. The FT demonstrates high morphological variability, with the most common configuration found in adults - a single insertion onto metatarsal 5 - being actually uncommonly found in foetuses.

Application value of imaging examination in the diagnosis of Muller-Weiss disease

To analyze radiological characteristics of Muller-Weiss disease, evaluate the clinical value of the imaging examination in diagnosis of Muller-Weiss disease. The imaging data of 26 patients with Muller-Weiss disease were collected from September 2015 to August 2020, including 7 males and 19 females, aged 43 to 68 years old with an average of (52.7±4.6) years old. In the X-ray examination observed the shape and position of the navicular bone. The talar-first metatarsal angle(TFM) was measured on the weight-bearing anteroposterior radiograph. The arch angle and angle between mid-axis of talus and mid-axis of the first metatarsal(Meary angle) were measured on the weight-bearing lateral radiographs. The morphology, density, adjacent joint space and position of the navicular bone were evaluated by computed tomography(CT), and magnetic resonance imaging(MRI) was used to observe the shape, signal, cartilage and surrounding soft tissue changes of the navicular bone. Among 26 patients, 21 cases were unilateral and 5 cases were bilateral;X-ray examination showed that the lateral part of navicular bone of foot was compressed and flattened, showing"comma like"or"drop like", navicular moved to the medial side, partial fragmentation of bone, peripheral articular hyperplasia, uneven density and narrowing of relationship gap. According to Meary angle and deformity degree of the affected foot on the lateral X-ray of the load-bearing foot, Maceira staging was performed. There were 0 cases in stageⅠ, 2 cases in stage Ⅱ, 11 cases in stage Ⅲ, 9 cases in stage Ⅳand 4 cases in stage Ⅴ. CT examination showed bone fragmentation, medial displacement of navicular bone and formation of the talocalcaneal joint. MRI examination showed the irregular shape and uneven signal of navicular bone, narrowing of joint space, talocalcaneal joint surface hyperplasia and cartilage destruction, tarsal joint effusion and swelling of surrounding soft tissue. Muller-Weiss disease has specific imaging manifestation, and an accurate diagnosis can be made based on the patient's age, gender, and clinincal history. Preoperative imaging examination can stage the disease, help clinicians to formulate better surgical plans, and postoperative imaging examination can better evaluate the surgical effect.

Bilateral Lisfranc Injury in a Young Female: A Case Report

Lisfranc injuries are relatively rare, accounting for only 0.2% of all injuries. It is even rarer to have this injury bilaterally, and not many case reports have been published on this topic. In this report, we present a case of a bilateral Lisfranc injury in a healthy 17-year-old woman that fell from a flight of stairs landing on both feet. The diagnosis was made by weight-bearing x-rays and computed tomography. Weight-bearing x-rays showed a subtle Lisfranc injury in the right foot with widening between the first and second rays and a disruption involving the overlapping bases of the lesser metatarsals as well as a left comminuted fracture of the proximal third and fourth metatarsals (MT) with intra-articular extension at the proximal fourth MT. CT scan of the right foot showed a fracture of the lateral margin of the medial cuneiform with a displaced bony fragment as well as a comminuted fracture of the third and fourth metatarsals with intra-articular extension and no dislocation. Surgical management, in the form of open reduction and internal fixation, was undertaken for both feet in the same setting. She had an expected course postoperatively and has been doing well, with no pain nor limitation in her activity at her six-month postoperative visit. Moreover, we present a brief review of similar published cases and an overview of Lisfranc injuries.