Metatarsal Research Articles

Tuberculous Osteomyelitis of the Fifth Metatarsal Treated Using the Induced Membrane Technique: A Case Report

Tuberculous osteomyelitis of the foot, an uncommon and rare entity, accounts for <0.01% of all tuberculous localizations. Osteomyelitis secondary to tuberculosis is difficult to diagnose and treat, requiring a high suspicion index. We report a case of tuberculous osteomyelitis of the fifth metatarsal bone treated with the induced membrane technique. Here, we report the case of a 40-year-old woman with a history of immunosuppressive treatment presented with a complaint of painful swelling of the left foot. Radiographs showed osteolytic lesions of the fifth metatarsal bone. Initial biopsy suggested tuberculosis. She was surgically treated with the induced membrane technique. Histology confirmed tuberculous osteomyelitis and antituberculous treatment was initiated. Full weight-bearing was allowed after 8 months. At 24 months follow-up, all symptoms were resolved. The radiographs showed an integrated graft. In conclusion, the presence of osteolytic lesions on a plain film should rise high suspicious for a possible infection requiring biopsy, and if confirmed, mandates surgical debridement and reconstruction. The induced membrane technique offers a mean to treat infectious bone defects. Level of Evidence: Level 4.

Anatomical study of the 3rd metacarpal bone of some mammals

The current study included the anatomical structure of the metatarsal bone in sheep in terms of the traditional structural description of the bone, as it was found that the metatarsal bone in the fore and hind limbs of adult sheep had no visible differences between it and animals, especially ruminants. The metacarpal \tarsal bone No. 3 was cylindrical in shape, with the presence of the metacarpal \tarsal bones 2 and 4 declines, articulated from the proximal end with the metacarpal and metatarsal bones whereas from the distal part with the fetlock joint and the first phalanx bone. The aim of the study is to determine whether the environment and its changes in Iraq have affected the animals and their bones in terms of length, thickness, and hardness.

Pharmacological inhibition of BCL-2 with the FDA-approved drug venetoclax impairs longitudinal bone growth

Treatment-related skeletal complications are common in childhood cancer patients and survivors. Venetoclax is a BCL-2 inhibitor that has shown efficacy in hematological malignancies in adults and is being investigated in pediatric cancer clinical trials as a promising therapeutic modality. Venetoclax triggers cell death in cancer cells, but whether it exerts similar effects in normal bone cells, is unknown. Chondrogenic ATDC5 cells, E20 fetal rat metatarsal bones, and human growth plate biopsies were treated with different concentrations of venetoclax. Female NMRI nu/nu mice were treated with venetoclax or vehicle for 15 days. Mice were X-rayed at baseline and at the end of the experiment to assess longitudinal bone growth and body weight was monitored throughout the study. Histomorphometric and immunohistochemical analyses were performed to evaluate treatment effects on the growth plate cartilage. Venetoclax decreased the viability of chondrocytes and impaired the growth of ex vivo cultured metatarsals while reducing the height of the resting/proliferative zone and the hypertrophic cell size. When tested in vivo, venetoclax suppressed bone growth and reduced growth plate height. Our experimental data suggest that venetoclax directly targets growth plate chondrocytes suppressing bone growth and we, therefore, encourage careful monitoring of longitudinal bone growth if treating growing children with venetoclax.

A PROSPECTIVE OBSERVATIONAL STUDY OF THE FUNCTIONAL OUTCOME OF SURGICAL MANAGEMENT OF INTRA-ARTICULAR CALCANEUM FRACTURE BY CLOSED REDUCTION WITH PERCUTANEOUS PINNINGS

The calcaneum is the greatest bone of the foot and is the major weight-bearing structure of the foot and the most common tarsal bone to fracture. Many treatment techniques are described in the literature but indications for specic techniques are undened. This study analyzes the outcome of the treatment of intra-articular tonguetype calcaneum fractures treated by Essex-leproesti technique. Methods- This prospective observational study aimed to evaluate the functional outcome of tongue-type intra-articular fracture by closed reduction with a percutaneous Steinmann pin. 16 patients with intra-articular tongue-type fracture were treated in Indra Gandhi government medical college and hospital, Nagpur from December 2020 to December 2022 with a minimum follow-up of 6 months. the functional outcome was assessed by the AOFAS Score. Most common cause for injury is fall from height. All patients were managed surgically and out of 16 patients, 4 cases(25%) had excellent, 9 cases (56%) had good and 5 cases (19%) had fair results. None of the patients in this series had poor results. As per our experience, the time for surgery is short and it can easily be performed even in the presence of swelling in the period immediately after injury also the risk of infection is very low.

Proximal segmental ostectomy under standing sedation for treatment of open comminuted axially displaced fractures of the fourth metatarsal bone in two horses

SummaryTwo cases with open, comminuted, axially displaced fractures of the proximal third of the fourth metatarsal bone were referred to the University Equine Hospital Vienna. Due to concerns regarding the risk of injury to the suspensory ligament and risk of implant infection with an open configuration, surgical treatment with proximal ostectomy of the fractured fourth metatarsal bone was performed in both cases. Based on telephone follow‐up, Case 1 was reported to be sound with no significant reaction at the surgical site 22 months following the procedure and Case 2 exhibited intermittent lameness, radiographically evident irregular new bone formation and some residual ultrasonographic changes of the proximal suspensory ligament 17 months after the procedure. Based on the results of this report, a proximal ostectomy facilitated by standing sedation and regional anaesthesia is a valid treatment option in cases of open, axially displaced fractures of the fourth metatarsal bone, minimising perioperative complications but not excluding long‐term postoperative complications.

Radiographic Evaluation of First Tarsometatarsal Joint Arthrodesis for Hallux Valgus Deformity: Does the Fusion of the First to the Second Metatarsal Base Reduce the Radiological Recurrence Rate?

Modified Lapidus arthrodesis (MLA) is a well-established treatment option for symptomatic hallux valgus deformity (HVD). However, recurrence of the deformity remains a concern. The goal of this study was to evaluate the effect of an additional intermetatarsal fusion on the radiographic recurrence rate after first tarsometatarsal (TMT-I) arthrodesis. This is a retrospective evaluation of 56 feet that underwent TMT-I arthrodesis for moderate to severe HVD. Twenty-three feet received an isolated arthrodesis of the TMT-I joint (TMT-I), whereas 33 feet received an additional fusion between the base of the first and the second metatarsal bone (TMT-I/II). Various radiological parameters were determined preoperatively, 6 weeks and at a mean of 2 years postoperatively. The intermetatarsal angle (IMA) and the hallux valgus angle (HVA) were significantly lowered at both follow-up evaluations in both groups. In the TMT-I/II group, the initial reduction of HVA was significantly higher (29.3° vs 21.1°). This difference disappeared by the second follow-up, leaving no significant differences between both techniques at final follow-up. Radiological recurrence rates of HVD were comparable in both groups. Isolated TMT-I arthrodesis provides reliable radiological results in the correction of HVD. Whether additional fusion of the first and second metatarsal base should be routinely performed remains unclear. Level 3.

Clinical Results of Nonvascularized Metatarsal Articular Bone Grafting for Osteochondral Defects of the Radiocarpal and Distal Radioulnar Joint.

Background Treatment of post-traumatic osteochondral defects in the radiocarpal and distal radioulnar joint with nonvascularized metatarsal articular bone grafting is an option to restore the joint (cartilage) surface and wrist function. Purpose To evaluate the clinical midterm results of 10 consecutive patients who were treated with a nonvascularized metatarsal bone graft for cartilage bone defects of the lunate facet, scaphoid facet, sigmoid notch, or the radial part of the ulnar head. Patients and Methods Patients with isolated osteochondral defects of the lunate facet, scaphoid facet, sigmoid notch, or radial part of the ulnar head, respectively, as a result of wrist trauma were retrospectively identified in a prospectively collected database. The patients symptoms were limited wrist motion and/or pain. Clinical results and complications were extracted from patient's medical files and two questionnaires consisting of the Patient-Rated Wrist Evaluation and additional questions regarding patient satisfaction and return to work and/or hobby. Results Minor complications occurred in three cases and required surgery. In five cases an acceptable donor site foot morbidity was seen at 1 year. One patient was not satisfied due to persistent wrist pain despite adequate range of motion. One patient could not return to its prior work. Another patient could not resume its hobby. Conclusion Retrospective evaluation of 10 cases with resurfacing of the scaphoid facet, sigmoid notch, and/or lunate facet, or radial part of the ulnar head has shown that osseointegration was possible without a vascular pedicle to the graft in all cases with a (mean) follow-up of 5 years. This technique may become an alternative treatment when implants become less available. Level of Evidence Level III.

AB155. SOH23ABS_003. Metatarsal stress fractures: an analysis of readability and quality of online health materials

AB155. SOH23ABS_003. Metatarsal stress fractures: an analysis of readability and quality of online health materials

Erratum to “Development of an elastic storage-release prosthetic foot that mimics the metatarsal bone head and midtarsal joint”

Acknowledgment was not stated in the original article.

Charcot Arthropathy and Osteomyelitis: A Case of Diabetic Foot Syndrome

Diabetes mellitus is a disease that affects millions around the globe. It also comes with a major complication, diabetic foot ulcers. Lower extremities having little to no vascularity in diabetic people leads to wounds that are unable to heal on their own. These wounds later become infected and cause osteomyelitis, a condition in which the infection in soft tissues of the lower extremities spread to the bones of the foot.Charcot arthropathy is one of the more serious foot issues that can arise from diabetic neuropathy. The soft tissues, joints, and bones of the foot or ankle are all impacted by Charcot. The joints in the foot or ankle might dislocate when the bones deteriorate and become brittle. Diabetes patients who have their soft tissues and bones infected might even have to get their extremities amputated if not managed right on time. We describe the case of a 66-year-old man with type 1 diabetes mellitus who presented to the emergency department with increasing pain in the right foot. There was a hyperemic discharge coming out of his wound which increased gradually over time. The patient’s been using Lantus and Novorapid and his blood glucose measurement at the time of admission was 466. Our patient said that he was hospitalized in the intensive care unit due to diabetic ketoacidosis 20 days before he applied to our emergency department, and his wounds, discharge, pain, and redness increased after this incident. We requested his anteroposterior and lateral radiographs of the right foot and a lower extremity CT. The scans were examined carefully and at last, amputation was recommended for the patient. The patient did decline our offer and wanted to go home with a dressing. Ampicillin/sulbactam and ciprofloxacin were started. We also recommended him see infectious diseases and plastic surgery consultants in the following daysI hope you may be interested in the results of our study in this direction.

Two rare cases of management of proximal phalanx spina ventosa

Tubercular dactylitis or spina ventosa is the tubercular infection of phalanges, metacarpals and metatarsals termed after cystic swelling of short tubular bones by tubercular infection. Here we presented two rare cases of spina ventosa in a 10 years old female and a 16 years old male patients. In both cases there was swelling of digits with stiffness. The radiographs were suggestive of chronic osteolytic infection with cortical destruction and diffuse sclerosis. We managed them with adequate surgical debridement, splintage and anti-tubercular therapy with good functional recovery. Spina ventosa or tubercular dactylitis is a rare condition and is often missed on diagnosis due to vague non-specific presentation, unavailability of rapid diagnostic tests and can be confused with other mimicking diseases. Any swelling over small tubular bones of hand or feet should raise the suspicion of spina ventosa, especially in endemic countries for tuberculosis. In neglected chronic infections, surgical debridement, curettage and splintage followed by anti-tubercular therapy based on histo-pathological reports is the treatment of choice with high protein diet and vitamin D supplementation ensures good outcome.

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

To observe clinical effect of percutaneous minimally invasive osteotomy with 8-shaped bandage and hallux valgus splint fixation in treating moderate hallux valgus. 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. 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. 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.

Malignant Bone and Soft Tissue Lesions of the Foot.

Malignant tumors of the foot are rare pathologies that can involve the skin, soft tissue, or bone. Due to their rarity, they are often misdiagnosed, resulting in inadequate excision and poor outcomes. A correct approach with a careful examination and radiological study, followed by a properly performed biopsy, is thus mandatory to avoid these pitfalls. The present article reviews the most common malignant bone and soft tissue lesions of the foot region, discussing their clinicopathological presentation, imaging features, and current concepts in treatment.

Clinical and genetic features of Kenny-Caffey syndrome type 2 with multiple electrolyte disturbances: A case report

Hypoparathyroidism, which can be sporadic or a component of an inherited syndrome, is the most common cause of hypocalcemia. If hypocalcemia is accompanied by other electrolyte disturbances, such as hypokalemia and hypomagnesemia, then the cause, such as renal tubular disease, should be carefully identified. An 18-year-old female visited our clinic because of short stature and facial deformities, including typical phenotypes, such as low ear position, depression of the nasal bridge, small hands and feet, and loss of dentition. The lab results suggested normal parathyroid hormone but hypocalcemia. In addition, multiple electrolyte disturbances were found, including hypokalemia, hypocalcemia and hypomagnesemia. The physical signs showed a short fourth metatarsal bone of both feet. The X-ray images showed cortical thickening of long bones and narrowing of the medulla of the lumen. Cranial computed tomography indicated calcification in the bilateral basal ganglia. Finally, the genetic investigation showed a de novo heterogenous mutation of "FAM111A" (c. G1706A:p.R569H). Through a review of previously reported cases, the mutation was found to be the most common mutation site in Kenny-Caffey syndrome type 2 (KCS2) cases reported thus far (16/23, 69.6%). The mutation was slightly more prevalent in females than in males (11/16, 68.8%). Except for hypocalcemia, other clinical manifestations are heterogeneous. As a rare autosomal dominant genetic disease of hypoparathyroidism, the clinical manifestations of KCS2 are atypical and diverse. This girl presented with short stature, facial deformities and skeletal deformities. The laboratory results revealed hypocalcemia as the main electrolyte disturbance. Even though her family members showed normal phenotypes, gene detection was performed to find the mutation of the FAM111A gene and confirmed the diagnosis of KCS2.

Development of an elastic storage-release prosthetic foot that mimics the metatarsal bone head and midtarsal joint

Development of an elastic storage-release prosthetic foot that mimics the metatarsal bone head and midtarsal joint

Minimally invasive Chevron Akin (MICA) osteotomy for severe hallux valgus.

The minimally invasive Chevron Akin (MICA) osteotomy has been widely used to treat hallux valgus (HV). The purpose of this study was to present a case series of patients with severe HV undergoing surgical treatment using the MICA procedure and to evaluate the clinical and radiographic outcomes. Retrospective study including 60 consecutive feet (52 patients) undergoing MICA for severe HV. The data were collected pre- and post-operatively at the last follow-up. Patients were clinically evaluated by the visual analog pain scale (VAS) and AOFAS hallux MTP-IP score. Radiographic assessments included measurements of hallux valgus angle (HVA), intermetatarsal angle (IMA), metatarsal (MT) length, distal metatarsal articular angle (DMAA), and plantar translation of MT head. The complications were recorded during the follow-up. The mean age was 59.9years, and the mean follow-up was 20.5months. The average AOFAS increased from 41.2 to 90.9 points, and the VAS from 8.1 to 1.3 at the last follow-up. The average HVA decreased from 41.2º to 11.6º, the IMA from 17.1º to 6.9º, and the DMAA from 17.9º to 7.8º. The average shortening of the first metatarsal and the plantar translation of the MT head was 5.1mm and 2.8mm, respectively. The most observed complication was hardware discomfort, observed in 5 feet (8.3%). There were two cases of recurrence (3.3%). MICA technique was demonstrated in this series of cases to be an effective procedure for severe HV, with a low rate of recurrence and an acceptable rate of complications. IV; case series.

Distal osteotomy of the first metatarsal bone for the correction of hallux valgus: comparison of the sagittal stability of two percutaneous techniques—a cadaveric study

BackgroundDistal first metatarsal osteotomy is used to correct mild or moderate hallux valgus (HV). We designed a cadaveric study to compare the resistance to axial load between two percutaneous distal first metatarsal osteotomies: Bösch osteotomy and percutaneous chevron. The first aim of this study was to develop a systematic technique for measuring the sagittal displacement on lateral foot X-rays. Our second objective was to measure the resistance to axial load for both of these osteotomies.MethodsTen pairs of freshly frozen cadaveric feet were randomly assigned to one of the two techniques investigated. Pre- and post-operative lateral X-rays were obtained. After surgery, the feet were placed under progressive axial loads up to 60 kg. Metaphyseo-diaphyseal angle (MDA) and the distance between bone fragments were measured, and the differences between the two techniques were statistically assessed.ResultsThe MDA decreased in both surgical techniques. The mean plantar tilt was −6.90 degrees (SD = 10.251) for chevron osteotomy and −5.34 degrees (SD = 16.621) for Bösch osteotomy. There was no significant difference between the techniques (p = 0.41).Regarding the distance between the bone fragments, the Bösch osteotomy produced more plantar displacement than the chevron osteotomy, which was statistically significant for the 10 and 20 kg loads (p = 0.031 and 0.04, respectively). At loads ≥ 30 kg, the bone fragment distance did not differ significantly between the techniques (p = 0.114).ConclusionsAlthough the chevron technique confers higher stability regarding fragment displacement during axial loading, both techniques increase the plantar angulation of the metatarsal head.Level of evidenceCadaveric study. Level V.

MODERN POSSIBILITIES OF ULTRASOUND SCAN IN DIAGNOSIS OF MORTON'S NEUROMA

About 60% of healthy people at least once in their lives complained of pain in the anterior foot that was diagnosed as Morton's neuroma. According to numerous resources, ultrasound scan is one of the leading methods for diagnosing the condition of the soft tissues in the foot, thus, this diagnostic technique can be considerably helpful in determining the nature and extent of the pathological condition and making the decision about the necessity of surgical treatment. Aim: to assess the potential of ultrasound investigation and to systematize the ultrasound criteria for Morton's neuroma using a two-dimensional mode, colour and energy mapping, and functional ultrasonography. Material and methods. We analyzed the findings obtained by the ultrasound scan of soft tissues in the foot of 26 people who complained of pain in the projection of 3-4 metatarsophalangeal joints. The following echographic data were evaluated: homogeneity, echogenicity, integrity of the soft tissues of the intermetatarsal spaces and tendons of the fingers, the presence of effusion in the articular capsules and tendon sheaths, the number of vascular signals in the affected area during power Doppler mapping. Results and discussion. In the control group of patients, the analysis of ultrasound has revealed the following echographic features: the contour of the cortical layer of the metatarsal bones is represented by a hyperechoic line with a clear acoustic shadow along it in all cases (100%); flexor tendons of the toes are located above the surfaces of the bones (100%); no masses are found in the intermetatarsal spaces in 100% of cases; the width of the intermetatarsal spaces is 5.0–9.0 mm in all cases (100%). In the main group of patients, the analysis of ultrasound findings has revealed the following structural changes: the contour of the cortical layer of the metatarsal bones is represented by a hyperechoic circular line with a clear acoustic shadow along it in 8 cases (30.7%); in 18 cases (69.3%) the contour of the cortical layer is uneven with a fuzzy acoustic shadow; flexor tendons of the toes are of reduced echogenicity and have heterogeneous structure in 16 cases (61.5%); space-occupying formations have been found in the intermetatarsal spaces of the III-IV toes in 24 cases (92.3%), and in the intermetatarsal spaces of the II-III toes and in 2 cases (7.7%); the width of the intermetatarsal spaces at the location of the mass formation in all cases (100%) is 10.0-15.0 mm. Conclusion. At the present, the access to ultrasound, its non-invasiveness, the absence of ionizing radiation, the possibility of dynamic observation, and relatively high accuracy in assessing the tibial nerve put it at the forefront in the diagnostic algorithm for detecting Morton's neuroma.

Septic Shock in the Course of Disseminated Tuberculosis in A COVID-19 Positive Patient with Concomitant AIDS

A 23-year-old male patient presented to the Provincial Hospital for Infectious Diseases in Warsaw, Poland in February 2022 with severe septic shock in the course of COVID-19 infection. The patient’s history and physical exam indicated a suspicion of HIV, TB, and COVID-19 triple coinfection. Numerous ulcers and phlegmon were present on the lower limbs and back with the patient complaining of difficulty walking. Laboratory tests came back positive for COVID-19, saliva tests were positive for active tuberculosis, and blood test results for the CD4 count were &lt; 200 cells/cubic millimeter confirming an AIDS diagnosis. Further testing and imaging revealed disseminated tuberculosis with involvement of bone in the left foot and thoracic spine, confirming Pott’s Disease. Treatment was started immediately for the septic shock with norepinephrine, vancomycin, meropenem, levofloxacin, and aggressive fluid resuscitation. COVID-19 treatment included oxygen mask therapy, systemic steroids and molnupiravir. Tuberculosis treatment was begun with isoniazid, rifampin, ethambutol, and pyrazinamide. Antiretroviral therapy (ART) was begun upon confirmed HIV/AIDS diagnosis using emtricitabine, tenofovir and dolutegravir. The patient was not previously on any ART and was not aware of his HIV/AIDS positive status.

Mechanical comparison of application of locking intramedullary nail to locking compression plate in the ovine metatarsus.

The metatarsal bone is commonly utilized in preclinical fracture models in sheep. A majority of studies achieve fracture stabilization with bone plating, but more recently intramedullary interlocking nails (IMN) have been utilized. The mechanical properties of this unique surgical technique utilizing an IMN has not yet been fully elucidated or compared to the traditional locking compression plating (LCP) technique. We hypothesize that a mid-diaphysis metatarsal critical-sized osteotomy stabilized with an IMN will provide equivalent mechanical stability to LCP with less variance of mechanical properties across specimens. Sixteen ovine hind limbs were transected at the mid tibia with soft tissue intact and utilized for implantation. A 3-cm osteotomy was created in the mid-diaphysis of all metatarsi. For the IMN group, a 147 mm × 8 mm IMN was implanted from distal to proximal through the sagittal septum of the distal metatarsus and the bolts locked in place using an IMN guide system. For the LCP group, a 3.5-mm 9-hole LCP was secured to the lateral aspect of the metatarsus with three locking screws in the proximal and distal holes leaving the central three holes empty. All metatarsal constructs were fitted with three strain gages on proximal and distal metaphyses and the lateral aspect of the IMN or LCP at the osteotomy site. Non-destructive mechanical testing was performed in compression, torsion, and four-point bending. The IMN constructs showed overall greater construct stiffness with less variance in strain between constructs than the LCP constructs in 4-point bending, compression, and torsion. IMN constructs may provide superior mechanical properties for a critical-sized osteotomy model of the ovine metatarsus when compared to lateral LCP constructs. Further in vivo investigation comparing characteristics of fracture healing between IMN and LCP is warranted.