Objective To investigate the effect of transplantation of the cutaneous iliac flap on repairing bone and soft tissue defect of metatarsal. Methods From October 1999 to December 2003, the cutaneous iliac flap was designed for the repair of bone and soft tissue defect of metatarsal in 4 male patients, whose ages ranged from 26 to 47, with skin graft for the coverage of the iliac flap. The duration of injury ranged from 1 to 5 months. The length of the defect ranged from 4 to 7 cm and the defect area ranged from 5 cm×3 cm to 9 cm×5 cm. Results One week after transplantation, complete survival of iliac flap was observed in 3 cases and partial survival in 1 case (but later proved survived). Callus was seen 1 month after transplantation and Kwires were removed 4months after transplantation. Patients were followed up for 5 to 24 months. There were no ulcers. The ability of walking and bearing was satisfying as well asthe function and shape. Conclusion With satisfying restoration of function and shape, transplantation of the cutaneous iliac flap with skin graft is an alternative to treat bone and soft tissue defect of metatarsal with one stage surgery.
ObjectiveTo evaluate the effectiveness of indirect fixation of the 3rd tarsometatarsal joint in the treatment of high-energy Lisfranc injury.MethodsBetween February 2015 and February 2019, 15 patients with high-energy Lisfranc injury were treated. There were 12 males and 3 females with an average age of 44.8 years (range, 29-73 years). The average time from injury to admission was 8.8 hours (range, 2-28 hours). According to Myerson classification, there were 6 cases of type A, 4 cases of type B2, 1 case of type C1, and 4 cases of type C2; 8 cases were open injury. The 3rd tarsometatarsal joint was injured in all patients, including intact intermetatarsal ligament in 7 cases, the 2nd-3rd intermetatarsal ligament injury in 6 cases, the 3rd-4th intermetatarsal ligament injury in 1 case, and the 2nd-3rd-4th intermetatarsal ligament injury in 1 case. Among them, the 3rd tarsometatarsal joint was not fixed directly and indirectly fixed by stabilized the 2nd and 4th tarsometatarsal joints in 13 cases. The 3rd tarsometatarsal joint was fixed with Kirschner wire in 2 cases for 1 patient had complete injury of the intermetatarsal ligament and the other 1 had comminuted fracture of the base of the 3rd metatarsal. The reduction of fracture and dislocation was evaluated by X-ray films, focusing on the re-displacement of the 3rd tarsometatarsal joint. The effectiveness was evaluated by American Orthopaedic Foot and Ankle Society (AOFAS) score and visual analogue scale (VAS) score.ResultsThirteen of the 15 patients were followed up 12-26 months, with an average of 15.6 months. One case had superficial infection of the incision and healed after symptomatic treatment; the other incisions healed by first intention. At last follow-up, the VAS score was 0-3 (mean, 1.1) and the AOFAS score was 70-99 (mean, 87.5). Twelve patients achieved anatomical reduction and 1 patient had increased talar-first metatarsal angle and the mild forefoot abduction. During the follow-up, no loss of reduction of the 3rd tarsometatarsal joint was found, while the spontaneous fusion of the joint was observed in 2 patients.ConclusionIn high-energy Lisfranc injury, as long as the intermetatarsal ligament is not completely destroyed and the bony structure of the tarsometatarsal joint is intact, the 3rd tarsometatarsal joint does not need to be fixed routinely, the stability of the joint can be obtained indirectly by fixing the adjacent tarsometatarsal joint.
To investigate the operative technique of treating Freiberg’s disease with dorsal wedge osteotomy and absorbable pin fixation, and to evaluate the cl inical outcome. Methods From June 2005 to June 2007, 8 patients with Freiberg’s disease were treated, including 2 males and 6 females aged 16-66 years old (average 36 years old). X-ray films revealed osteosclerosis, collapse of the metatarsal head and ischemic necrosis of the second metatarsal head. According toSmill ie classification system, there were 4 cases of stage II, 3 of stage III and 1 of stage IV. The duration of symptoms was 6-36 months (average 19 months). After dorsal wedge osteotomy, the metatarsal heads were rotated to reconstrust the joint surface, then 3-4 pieces of absorbable pin 1.5 mm in length were implanted for fixation. Results All wounds healed by first intention, and no early postoperative compl ications occurred. Five patients were followed for 11-35 months (average 14 months) and had significant pain rel ief. At 3 months after operation, the dorsal-flexion of metatarsophalangeal joint was improved by 0-50° (average 21°), and the plantar-flexion was increased by 0-10° (average 5°). X-ray films showed that solid union of the osteotomy was achieved in all patients at 8-13 weeks after operation (average 10 weeks). Average shortening of metatarsal was 1.7 mm (range 1.3-2.0 mm). All patients returned to sports and recreational activities at 4 months after operation, except one case of stage IV who had constant swelling and stiffness in the joint and was improved at 12 months after operation. Conclusion Dorsal wedge osteotomy in complex with absorbable pin fixation is an effective procedure for stage II and III Freiberg’s disease, because it is capable of reconstructing the metatarsophalangeal joint effectively, allowing early joint motion and avoiding a second operation.
Objective To investigate the effectiveness of nickel-titanium shape memory staples in treating multiple metatarsal fractures. MethodsThe clinical data of 27 patients with multiple metatarsal fractures who were treated between January 2022 and June 2023 and met the selection criteria were retrospectively analysed. The cohort consisted of 16 males and 11 females, aged 33-65 years (mean, 47.44 years). The causes of injury included heavy object impact in 11 cases, traffic accidents in 9 cases, and crush in 7 cases. Simultaneous fractures of 2, 3, 4, and 5 bones occurred in 6, 6, 4, and 8 cases, respectively, with tarsometatarsal joint injury in 3 cases. Fixation was performed using staples for 16, 22, and 9 fractures in the metatarsal neck, shaft, and the base, respectively, and 5 tarsometatarsal joint injuries. Preoperative soft tissue injuries were identified in 8 cases and classified according to the Tscherne-Oestern closed soft tissue injury classification as type Ⅰ in 5 cases and type Ⅱ in 3 cases. One case of type Ⅱexhibited preoperative skin necrosis. The patients were treated with fixation using nickel-titanium shape memory staples. Complications and fracture healing were documented. At last follow-up, the American Orthopaedic Foot and Ankle Society (AOFAS) forefoot score was used to evaluate the function, and the visual analogue scale (VAS) score was used to evaluate the pain. Results The 27 patients were followed up 9-19 months (mean, 12.4 months). Postoperative X-ray films revealed no loss of fracture reduction, and all fractures achieved bony union. No internal fixator loosening, breakage, or other mechanical failures was observed. The mean fracture healing time was 3.13 months (range, 3-4 months). Postoperatively, 4 cases (2 of Tscherne-Oestern type Ⅰ, 2 of type Ⅱ) developed superficial skin necrosis, which resolved with dressing changes. No infection was observed in the remaining patients, and all wounds healed. At last follow-up, the AOFAS forefoot score ranged from 70 to 95, with an average of 86.6, of which 19 cases were excellent, 6 cases were good, and 2 cases were fair, with an excellent and good rate of 92.6%; the VAS score ranged from 0 to 3, with an average of 0.9, of which 24 cases were excellent, and 3 cases were good, with an excellent and good rate of 100%. Conclusion The use of nickel-titanium shape memory staples in the treatment of multiple metatarsal fractures can effectively protect local skin and soft tissues and minimize secondary damage associated with internal fixator insertion. It is a viable surgical option for management of multiple metatarsal fractures.
ObjectiveTo summarize the technique and effectiveness of double metatarsal osteotomy for treating severe hallux valgus with increased distal metatarsal articular angle (DMAA).MethodsBetween June 2014 and December 2017, 64 patients (94 feet) of severe hallux valgus with an increased DMAA were treated with the double metatarsal osteotomy (distal metatarsal Reverdin osteotomy+proximal metatarsal open wedge osteotomy) combined with Akin osteotomy and soft tissue surgery to correct the deformity. There were 10 males (15 feet) and 54 females (79 feet) with an average age of 44.5 years (range, 26-66 years), including 34 of unilateral foot and 30 of bilateral feet. The Maryland metatarsophalangeal joint score of the American Orthopaedic Foot and Ankle Society (AOFAS) was 54.3±7.4 and the visual analogue scale (VAS) score was 6.0±2.0. The pre- and post-operative AOFAS score, VAS score, DMAA, hallux valgus angle (HVA), first-second intermetatarsal angle (1-2IMA), and the first metatarsal length (FML) were recorded and compared.ResultsAll incisions healed by first intention. All patients were followed up 12-15 months, with an average of 13.2 months. The complications occurred in 4 feet, including 1 foot of hallux stiffness, 1 foot of numbness at the edge of the wound, 1 foot of metastatic metatarsalgia, and 1 foot of metatarsal bone necrosis. At 1 year after operation, the Maryland metatarsal joint score of AOFAS was 89.2±7.4, showing significant difference compared with preoperative score (t=18.427, P=0.000); and the effectiveness was rated as excellent in 78 feet, good in 12 feet, poor in 3 feet, and bad in 1 foot, with an excellent and good rate of 95.7%. The VAS score was 1.5±2.0, showing significant difference compared with the preoperative score (t=10.238, P=0.000). The X-ray films showed that the osteotomies achieved bony healing at 3 months after operation. There were significant differences (P<0.05) in HVA, 1-2IMA, and DMAA between preoperation and 6 months and 1 year after operation; but no significant difference was found in FML between preoperation and 1 year after operation (t=0.136, P=0.863).ConclusionFor the patients with severe hallux valgus with increased DMAA, the double metatarsal osteotomy can significantly relieve the clinical symptoms and improve the imaging parameters with less postoperative complications.
Objective To investigate the effect of first to third metatarsus defect and the effect of reconstruction with ilium on foot function. Methods The first to third metatarsus defect was simulated in a 3D foot model and rebuilt by ilium. The maximal displacement and stress calculated by the method of finite elements were used as the index of estimation. Five cases treated from Mar. 1996 to Jan. 2003 with metatarsus defect rebuilding by free vascular iliac bone incorporating free flapwere evaluated. Results Foot function was affected largely by the defect of the first to third metatarsus. Compared with the normal foot, the maximal displacement was increased by 2.15 times and the maximal stress was increased by 2.12 times in 100% defected foot, and in 50%-defected foot maximal displacement and stress were increased by 1.65 times and 2.05 times respectively. Follow-up had been conducted for 1 to 2 years. All bones and flaps of the 5 cases survived (2 excellent, 2 good, and 1 passable) by function evaluation. Conclusion The first to third metatarsus defect should be repaired, and the method of transplanting iliac bone added by flap is effective.
ObjectiveTo explore the effectiveness of the first-stage debridement and Ilizarov metatarsal bone lengthening in treatment of diabetic foot ulcer complicated with chronic osteomyelitis of metatarsal head.MethodsBetween January 2015 and October 2018, 8 cases (9 feet, 11 sites) of diabetic foot ulcer complicated with chronic osteomyelitis of metatarsal head were treated by first-stage debridement and Ilizarov metatarsal bone lengthening. There were 3 males (4 feet, 5 sites) and 5 females (5 feet, 6 sites), with an average age of 57.5 years (range, 44-65 years). According to diabetic foot Wagner grade, 6 cases (7 feet) were grade 3 and 2 cases (2 feet) were grade 4. The chronic osteomyelitis located at left foot in 4 cases, right foot in 3 cases, and bilateral feet in 1 case. The duration of chronic osteomyelitis was 1-5 years (mean, 3.1 years). The chronic osteomyelitis site was the 1st metatarsal head in 3 feet, the 3rd metatarsal head in 1 foot, the 4th metatarsal head in 1 foot, and the 5th metatarsal head in 6 feet. Two patients had chronic osteomyelitis at 2 sites on 1 foot. The length of lengthened metatarsal bone, lengthening time, and the time of wearing external fixation frame were recorded, and the external fixation frame index was calculated. The healing conditions of foot ulcer and lengthening bone segment were observed, the healing time was recorded, and the healing index of lengthening bone was calculated. The ankle function was evaluated according to the American Orthopedic Foot and Ankle Society (AOFAS) score criteria.ResultsAll patients were followed up 9-26 months with an average of 15.0 months. Except pin tract infection during the bone lengthening period, there was no complications such as skin necrosis and vascular or nerve injury occurred during treatment. The length of lengthened metatarsal bone was 12-35 mm with an average of 20.5 mm; the metatarsal bone lengthening time were 21-84 days with an average of 57.8 days. The average time of wearing external fixation frame was 14.6 weeks (range, 10.4-21.1 weeks) and the external fixation frame index was 54.3 days/cm (range, 42.9-59.2 days/cm). The ulcer wound healed with an average healing time of 30.5 days (range, 19-70 days) and no ulcer recurrence was observed during follow-up. Bone healing was obtained in all bone lengthening segments, and the average healing index was 42.5 days/cm (range, 37-51 days/cm). The average AOFAS score was 91.7 (range, 87-95); 5 feet were excellent and 4 feet were good. The excellent and good rate was 100%.ConclusionThe metatarsal bone lengthening under Ilizarov law of tension-stress after debridement can promote diabetic foot ulcers healing and reconstructing the length of metatarsal to retain the function of metatarsal load and avoid amputation. This is an effective method for the treatment of diabetic foot ulcer complicated with chronic osteomyelitis of metatarsal head.
ObjectiveTo summarize the research and clinical application progress of foot lengthening surgery. Methods Relevant research literature on foot lengthening surgery in recent years at home and abroad was reviewed, and a summary was made from aspects such as the types of lengthening surgery, the types of foot diseases treated by clinical application, effectiveness, and complications. ResultsBone defects and shortening deformities of the foot are relatively common clinically. As an innovative treatment method, foot lengthening surgery has gradually attracted attention, mainly including the Ilizarov technique and one-stage bone grafting lengthening surgery. The former promotes bone regeneration based on the tension-stress principle and is widely used in the treatment of calcaneal defects and congenital metatarsal brachymetatarsia, achieving good curative effects. However, there are also complications such as pin-tract infection, joint stiffness and contracture, non-union and delayed union of bone, re-fracture, and alignment deviation. The latter has a short treatment cycle, but the lengthening length is limited. Bone graft resorption and soft tissue complications are its main complications. ConclusionFoot lengthening surgery will develop towards the direction of personalization, intelligence, and precision. With the help of multi-center research, biological materials, and intelligent technologies, the effectiveness and safety will be further improved to better restore the function and appearance of the foot.
Objective To explore the effectiveness of transverse double “8”-shaped tension band technique in the treatment of Lawrence zoneⅠfracture of the 5th metatarsal base. Methods Between February 2019 and October 2021, 15 patients with Lawrence zoneⅠfracture of the 5th metatarsal base were treated with transverse double “8”-shaped tension band technique. There were 8 males and 7 females, with a median age of 40 years (range, 23-59 years). The fractures were caused by sprains. The time from injury to operation was 3-7 days (mean, 4.1 days). X-ray films were taken to observe the fracture healing and the anchor looseness and detachment. The foot function was evaluated by American Orthopaedic Foot and Ankle Society (AOFAS) score, visual analogue scale (VAS) score, and the eversion angle of the calcaneal talus joint. Results The incisions healed by first intention after operation in 14 cases and the incision healed poorly in 1 case. All patients were followed up 8-12 months (median, 10 months). The imaging examination showed that all fractures healed well, with a healing time of 10-14 weeks (mean, 11.7 weeks). At last follow-up, AOFAS score was 82-100 (median, 98); 13 cases were excellent and 2 cases were good, with an excellent and good rate of 100%. VAS score was 0-3 (median, 1). Three cases had mild limited ankle joint range of motion, while 12 cases had normal range of motion. The eversion angle of the calcaneal talus joint was 25°-32° (median, 30°). Conclusion The application of transverse double “8”-shaped tension band technique for Lawrence zone Ⅰ fracture of the 5th metatarsal base has advantages such as simple operation, avoidance of secondary operation, and reduction of foreign body sensation, with definite effectiveness.
Objective To evaluate the functional and aesthetic evaluation of external fixator lengthening through plantar approach for fourth brachymetatarsia. Methods A retrospective analysis was conducted on 20 patients (23 feet) with fourth brachymetatarsia who met the selection criteria between January 2016 and January 2024, including 3 males and 17 females, with 8 left, 9 right, and 3 bilateral cases. The mean age was 24.7 years (range, 14-51 years). The preoperative metatarsal shortening length was (13.8±3.2) mm. The preoperative American Orthopaedic Foot and Ankle Society (AOFAS) forefoot score was 79.5±3.9, the visual analogue scale (VAS) score of appearance satisfaction was 1.7±0.8, and the appearance index (AI) score was 13.6±0.9. All patients underwent external fixator lengthening through plantar approach. The lengthening length of metatarsal bone, lengthening ratio, healing time, and healing index were recorded. Functional outcomes were assessed using the AOFAS forefoot score, VAS score of appearance satisfaction, and quality-of-life impact with AI questionnaire. Results All 20 patients were followed up 14-55 months with an average of 36.3 months. During the follow-up, complications occurred in 4 cases (17.4%), including 2 cases of metatarsophalangeal joint stiffness, which had no significant effect on the function and appearance. Delayed union of osteotomy occurred in 1 case (healed at 12 weeks after operation). Pin loosening occurred in 1 case and recovered after outpatient reinforcement. No complications related to plantar scar occurred. At last follow-up, the lengthening length of metatarsal bone was (13.9±3.1) mm, and the lengthening ratio was 25.8%±5.6%. All cases achieved bony union, with a mean healing time of (64.3±12.5) days and a healing index of (46.9±4.8) d/cm. At last follow-up, AOFAS score was 98.9±2.1, the VAS score of appearance satisfaction was 9.3±0.7, and the AI score was 0.6±0.8, which significantly improved when compared with those before operation (t=27.398, P<0.001; t=32.994, P<0.001; t=56.135, P<0.001). Conclusion External fixator lengthening through plantar approach is a safe and effective technique for fourth brachymetatarsia, achieving satisfactory functional and aesthetic outcomes.