Brachymetacarpia and brachymetatarsia are rare congenital presentations denoted by shortening of metacarpals and metatarsals respectively, in which the deformity usually presents around childhood/early adolescence.The aetiology is usually congenital besides several other syndromic or endocrinologic associations.Cosmetic issues such as absence of a normal-looking knuckle while making a fist or disruption of finger-tip curvature besides functional issues are the main indications for surgical intervention in brachymetacarpia.In the foot, apart from cosmetic issues, pain due to transfer metatarsalgia as well as callosities along with toe deformities which lead to difficulty of using footwear are the main indications for intervention.Lengthening of the affected bone, either acute with grafting or gradual, is the mainstay of treatment. Gradual lengthening can be either single-stage as in callotasis, or two-stage where the primary procedure is followed by bone grafting after the length has been achieved.Adolescence, specifically between 12 and 15 years, is the preferred period for surgical intervention in these cases.Cite this article: EFORT Open Rev 2021;6:15-23. DOI: 10.1302/2058-5241.6.200087

Plantar fasciitis (PF) is characterized by pain on weight-bearing in the medial plantar area of the heel, metatarsalgia (MTG) by pain on the plantar surface of the forefoot radiating into the toes. Reliable figures on lifetime prevalence in Germany are lacking. This review is based on pertinent publications retrieved from a selective search in PubMed, on guidelines from Germany and abroad, and on the authors' clinical experience. Plantar fasciitis is generally diagnosed from the history and physical examination, without any ancillary studies. In 90-95% of cases, conservative treatment (e.g., stretching exercises, fascia training, ultrasound therapy, glucocorticoid injections, radiotherapy, shoe inserts, and shock-wave therapy) brings about total, or at least adequate, relief of pain within one year. Intractable pain is an indication for surgical treatment by plantar fasciotomy and/or calf muscle release. In metatarsalgia, a directed diagnostic work-up to find the cause is mandatory, including a search for excessive mechanical stress due to abnormal foot posture, neuropathic pain, rheumatoid arthritis, aseptic bony necrosis, or malignant disease; imaging studies and pedobarography are needed. For causally oriented treatment, a wide range of conservative and surgical measures can be considered. The reported results of treatments for plantar fasciitis and metatarsalgia are heterogeneous. The efficacy of the individual measures should be studied in randomized controlled trials.

Objective To investigate the cause of metastatic metatarsalgia after hallux valgus surgery and the clinical outcomes of Weil osteotomy for metastatic metatarsalgia after hallux valgus surgery. Methods From July 2009 to Janurary 2012, data of 27 patients （27 feet） with metastatic metatarsalgia of 2nd to 4th head of metatarsal bone after hallux valgus surgery who had been treated by Weil osteotomy were retrospectively analyzed. There were 1 male and 26 females with an average age of 51 years （range, 28-73 years）. Metatarsalgia occurred 6-24 months after operation for hallux valgus. 13 feet underwent mini-invasive cervi-cal wedge osteotomy of the first metatarsal, 7 with Chevron procedure, 5 with Akin procedure, and 2 with Lapidus procedure. No shortening in first metatarsal was found in 5 feet with Akin osteotomy, while there were varying degrees of shortening in first meta-tarsal in the remaining 22 feet. The clinical results were evaluated by American Orthopaedic Foot and Ankle Society （AOFAS） and visual analogue scale （VAS） scores. The preoperative and postoperative plantar pressure changes were tested by plantar pressure tester. Results 25 Patients were followed up for 12-42 months （average, 24 months）. Among these 25 cases, the metatarsalgia of 23 cases were completely disappeared. The metatarsal plantar lateral metastatic pain occurred in the remaining 2 cases （2 feet） and 1 was relieved by the foot pad, 1 was cured by re-Weil osteotomy. AOFAS score was 46.82 ± 6.13 before surgery and 90.63 ± 1.65 after surgery. The VAS score was 7.5 （6, 7） before surgery and 0.5 （0, 1.0） after surgery. The last follow-up, according to the score of AOFAS toe metatarsophalangeal-interphalangeal joint, of which 23 cases were excellent, 1 good, 1 poor;the excellent and good rate was 96%（24/25）. Preoperative pressure under 2nd to 5th metatarsal head were 3.12±1.62 Pa, 5.81±1.92 Pa, 4.63± 2.10 Pa, 3.37±1.57 Pa, 1.67±1.20 Pa and postoperative were 3.33±1.35 Pa, 3.89±1.08 Pa, 3.65±1.96 Pa, 2.25±1.23, （1.48±1.11） Pa. Postoperative pressure under 2nd to 5th metatarsal head were significantly decreased. Conclusion Weil osteotomy can effec-tively adjust the length of the metatarsal and the height of metatarsal head, thus effectively improve the pressure under the metatar-sal head, so it could reach a good effect in the treatment of metastatic metatarsalgia after hallux valgus surgery. Key words: Metatarsalgia Hallux valgus Osteotomy Surgical procedures; operative

Civinini-Morton’s metatarsalgia is characterized by a swelling, known as “neuroma”, of the common digital plantar nerve (CDPN), which may cause extreme pain and disability. Microscopically, the affected nerve presents extensive concentric perineural fibrosis. It is considered an entrapment syndrome, due to the impingement of CDNP against the stiff deep transverse metatarsal ligament (DMTL). According to this hypothesis, some surgeons suggest neurolysis, by cutting the DMTL1, as a treatment, instead of generally performed neurectomy. Also some rehabilitation techniques affirm that modifying perineural connective tissue improves patients’ symptoms2. To better study the relationships of the nerve with DTML and deep fasciae of the foot we dissected 15 feet and analyzed 30 MRI. Data from dissections confirm that CDPN’s bifurcation in the second and third webspace is always distal to DTML. Proximal to the metatarsal heads, the nerve is encased by a sheath made by concentric sleeves of fibrous and loose connective tissue continuous with vascular sheaths and deep fasciae of the foot: this arrangement, similar to a “telescope”, may provide a channel to allow the nerve to move independently from surrounding structures, being protected against traction during walking. In the intermetatarsal space, fascial septa connect DMTL, tendon sheaths and plantar fascia, and bound lobules of adipose tissue, more abundant on plantar aspect of the neurovascular bundle: these, along with adipocytes contained between concentric layers of neural sheath, could cushion compressive stresses. Distally to DMTL this protective system is less represented. MRI shows marked inter-individual morphologic variation of the intermetatarsal channel: its size varies from 16.22 mm2 to 64.43 mm2, with a mean value of 37.34 mm2. Its shape ranges from oval or rounded (with a big distance between DMTL and plantar fascia) to roughly rectangular (with a narrow distance); in some people the channel is filled with adipose tissue, while in others fibrous tissue prevails. Fascial septa also vary among people, ranging from barely discernible to 1.2 mm thick, while DMTL is relatively constant (from 0.5 mm to 1.0 mm thick). Plantar fascia varies from 0.6 to 1.1 mm. People who lack an efficient “sliding and cushioning system” could tolerate less mechanical stresses during walking and thus be at increased risk of Civinini-Morton’s syndrome. Perineural scarring (which forms the neuroma) consequent to nerve impingement could, by destroying neural sheath’s structure, further impair nerve protection and worsen symptoms.

To evaluate the correlation between the length of first metatarsal, hallux valgus angle (HVA), intermetatarsal 1-2 angle (IMA1-2), plantar appearance, sesamoid position and postoperative 2-5 transfer metatarsalgia. Retrospective analysis was performed for the clinical data of 375 cases (626 feet) undergoing osteotomy of first metatarsal with mini-incision. All cases were examined radiographically via weight-bearing and lateral views. HVA, IMA1-2 and the length of first metatarsal were measured preoperatively and postoperatively. Forefoot plantar pressure was measured during walking by Foot scan system preoperatively and postoperatively. After a mean follow-up period of 12-30 (18.5 ± 6.8) months, all patients had satisfactory bone healing without late healing or disunion. There were superficial wound infection (n = 1, 1 foot) and suture reaction (n = 1, 1 foot). HVA was 7.18° ± 4.55° postoperatively and corrected by 30.54°; IMA1-2 5.07° ± 1.70° and corrected by 12.33°. The number of shorting of first metatarsal during 0-2 mm was 424 feet, there was 1 case of transfer metatarsalgia at rays 4; the number during 2-4 mm was 186 feet, there were 5 cases of transfer metatarsalgia at rays 2. The center of pressure shifted laterally; the number during 2-4 mm was 16 feet, there were 4 cases of transfer metatarsalgia at rays 2 and 3. The center of pressure shifted evidently medially; the shorting of first metatarsal was 4.8 ± 0.46 mm. A negative correlation was found between length of metatarsal and transfer metatarsalgia at rays 2 and 3. No correlation existed between transfer metatarsalgia at rays 2 and 5, HVA and IMA1-2. A positive correlation existed between HVA decrease and patient satisfaction with their postoperative foot alignment. There was no correlation between lengthening of metatarsal and IMA1-2 decrease. Length preservation of first metatarsal seems to prevent the postoperative transfer metatarsalgia on second and third rays. The shorting of first metatarsal should be no more than 2 mm.

Objective To explore the effect of the treatment of forefoot deformities caused by rheumatoid arthritis by the method of the first metatarsophalangeal joint fusion combined with metatarsophalangeal arthroplasty from the second to the fifth toe.Methods The data of 19 patients with forefoot deformities caused by rheumatoid arthritis was retrospectively studied after receiving the treatment by the method of the first metatarsophalangeal joint fusion combined with metatarsophalangeal arthroplasty from the second to the fifth toe from June 2007 to October 2010.There were 17 females (31 feet) and 2 males (4 feet) with an average age of 56 years (range,33-73 years).The American Orthopaedic Foot and Ankle Society (AOFAS),visual analogue scale (VAS) were applied.Hallux valgus angle (HVA) and intermetatarsal angle (IMA) were measured to investigate the changes in forefoot deformity preoperatively and postoperatively respectively.Results In 17 cases,the appearances of forefoot were improved in different degrees.The metatarsalgia disappeared completely in 29 feet.In other 3 feet,the fifth metatarsal metastatic metatarsalgia appeared and the pain was relieved after the forefoot decompression pad treatment.The distal end of hallux was excised due to necrosis.Forming joint have different degrees of anchylosis.The AOFAS improved from 46.82±6.13 preoperative to 84.25±2.87 postoperative,while the VAS,HVA,IMA decreased from 9.03±1.82,38.96°±10.13° and 15.87°±3.43° to 2.12±0.67,15.84°±5.12° and 10.35°±1.67° respectively.Conclusion The effect of the treatment for forefoot deformities caused by rheumatoid arthritis by the first metatarsophalangeal joint fusion combined with metatarsophalangeal arthroplasty from the second to the fifth toe is excellent. Key words: Arthritis, rheumatoid; Foot deformities, acquired; Metatarsophalangeal joint; Arthrodesis

Objective To explore the causes of failed Hallux valgus surgery and its corresponding salvage interventions. Methods The data of 23 patients （3 males, 20 females） who received hallux valgus revision surgeries, from December 2005 to December 2011 was retrospectively analyzed. Their average age was 63.1 years （range, 28-85 years）. The mean follow-up duration of the first operation was 27.6 months （range, 6-96 months）. The reasons for the failed operations were firstly analyzed and appropriate revision procedures were then chosen based on their clinical manifestation, physical examination and X-ray findings. Results The causes of the 23 primarily failed hallux valgus patients included 5 recurrent hallux valgus de- formity, 2 hallux varus, 5 metatarsalgia, 7 internal fixations looseness and 4 internal fixations breakdown. The salvage surgical procedures consisted of 3 first tarsometatarsal joint fusions, 1 of first metatarsal basal osteotomy and Akin osteotomy again after 2 years, 2 of metatarsophalangeal joint arthrodeses and 5 Weil os- teotomies, 11 removals of internal fixation. The remainder 1 patient had combined first tarsometatarsal joint fusions and metatarsophalangeal joint arthrodesis. The mean followup duration was 16.5 months （range, 6-36 months）. The postoperative average American Orthopaedic Foot and Ankle Society （AOFAS） metatarsopha- langeal-interphalangeal scale was 89.2＋8.9, which was 65.3＋7.5 before revision surgeries. Excellence rate was 91.3% （21/23）, with 17 cases whose effect were excellent, 4 good and 2 fair. Conclusion The reasons of failed hallux valgus surgery varied a lot due to the diversities of surgical methods including relapse, varus, metatarsalgia, internal fixation, break and so on. Fully understand of the pathogenesis as well as clinical presentations were critical for surgeons. Appropriate candidate, proper internal fixation material and suitable surgical methods were other assurances for successful hallux valgus treatments. The decision of revision pro- cedure should be individualized and take clinical manifestation, physical examination as well as radiographic findings into account. Key words: Hallux valgus; Reoperation; Postoperative complications

Objective To explore the curative effect of the operation of double wedge osteotomy of the first metatarsal for correction of severe hallux valgus. Methods The data of 62 patients （87 feet） with severe hallux valgus caused by enlarged distal metatarsal articular angle （DMAA） who were followed up after receiving the treatment of double wedge osteotomy of the first metatarsal from January 2008 to December 2011 were analyzed retrospectively. There are 9 males （14 feet）, and 53 females （73 feet）, with an average age of 56 years （range, 28-70 years）. Preoperative radiographs showed hallux valgus angle （HVA） was 48.6° in average, intermetatarsal angle （IMA） was 19.8° in average, and DMAA was 22.1° in average. The operation plan was made based on the preoperative deformity, and the osteotomy site, the angle, the capacity of osteotomy was all based on preoperative measurement. Compare the changes of HVA, IMA, DMAA before and after operation. The changes were also compared before and after the internal fixation extraction. The curative effect was observation based on American Orthopaedic Foot and Ankle Society （AOFAS） propodium score standard. Results Sixty-two patients （87 feet） were followed up for 10 to 57 months, with an average of 21 months. HVA （14.6°±1.2°IMA （7.9°±0.7°）, DMAA （7.7°±0.9°） were all satisfied 6 months after the opera- tion. Stiff occurred in 2 patients after the operation. Cutaneous nerve injury occurred in 2 patients, and metastatic metatarsalgia occurred in l patient. No sever recurrence of deformity, bone nonunion and bone necrosis was found in all the patients. AOFAS score reached 91.8±1.8 one year after the operation, which was 28.4±9.1 preoperatively. Among them, 49 feet were rated as excellent, 31 as good, and 7 as fair. The ex- cellent and good rate was 92% （80/87）. Conclusion The first metatarsal double osteotomy can effectively correct the severe hallux valgus deformity with enlarged DMAA with few complications. It achieves good ef- fect. Patients can bear part of the loading in the early stage of recovery after operation. [Key words] Osteotomy; Hallux valgus; Treatment outcome

Objective To evaluate the long-term results of minimal incision osteotomy for hallux valgus.Methods From February 1996 to May 1999,372 cases(705 feet)with hallux valgus were treated with minimal incision osteotomy.Seventy-nine cases after surgery were followed up for more than 5 years,including 6 males(10 feet)and 73 females(140 feet)with an average age of 47 years(range,13-75 years).The average follow-up time was 7.5 years(range,5.3-13.2 years).The preoperative and postoperative hallux valgus angles(HVA),intermetatarsal angles(IMA),the tibial sesamoid position(TSP),American orthopedic foot and ankle society(AOFAS)score,range of movement of the first metatarsophalangeal joint,and lateral metatarsalgia etc.were observed and measured.And the clinic outcome were studied and evaluated.Results Based on Wen Jian-min's clinic curative effect evaluation criterion(2001),56 feet(37.3%)were excellent,88 feet(58.7%)good ,6 feet(4.0%)fair.The rate of excellent or good was 96.0%(144/150).The postoperative mean AOFAS score was 84.20±4.32 points(range,60-100 points).The mean HVA decreased from 33.28 to 12.31 degrees,the mean IMA from 11.75 to 6.80 degrees.The TSP was corrected from an average preoperative grade of 4.29 to a grade of 3.07 at final follow-up.There are no nonunion or delayed union of osteotomy,avascular necrosis of the 1st metatarsal head,infection,hallux varus.Four feet(2.7%)had numbness in the medial of the big toe.The 1st metatarsophalangeal joint range of motion decreased from 70.20 to 69.53 degrees.There were 97 feet(64.7%)with the 2-5 metatarsalgia before operation,and 35 feet(23.3%)disappeared,54 feet(36.0%)improved,8 feet(5.3%)aggravated after operation.Conclusion Minimal incision osteotomy technique is sound and reliable method to treat hallux valgus.The osteotomy technique is simple,and could provide satisfactory long-term results with lower complication rate. Key words: Hallux valgus; Surgical procedures,minimally invasive; Treatment outcome

Mechanically induced metatarsalgia

Oblique sliding metatarsal osteotomy for pressure metatarsalgia.