ObjectiveTo investigate the surgical methods and effectiveness to use the iliac flap combined with anterolateral thigh flap for repair of the first metatarsal bone and large skin defect.
MethodsBetween January 2013 and January 2016, iliac flap combined with anterolateral thigh flap was used to repair the first metatarsal bone and large skin defect in 9 patients. There were 5 males and 4 females, with a median age of 15 years (range, 10 to 60 years). The causes included traffic accident injury in 6 cases and crush injury of machine in 3 cases. The average time from injury to operation was 3 hours to 14 days (mean, 7 days). The size of skin soft tissue defect ranged from 10 cm×6 cm to 20 cm×10 cm. The size of first metatarsal bone defect ranged from 2 cm×1 cm to 5 cm×1 cm. The size of iliac flap was 3.0 cm×1.5 cm to 6.0 cm×1.5 cm, and the size of anterolateral thigh flap was 10 cm×6 cm to 20 cm×10 cm. The donor site was directly sutured or repaired by free skin graft.
ResultsAfter operation, the composite flaps survived with primary healing of wound; the skin grafts at donor site survived and the incision healed by first intention. All patients were followed up 6 months to 2 years (mean, 1.6 years). X-ray examination showed that the bone healing time was 3.5-5.0 months (mean, 4 months). The flap had soft texture, good color and appearance. All patients could normally walk. According to the American Orthopaedic Foot and Ankle Society (AOFAS) standard, the foot function was excellent in 6 cases and good in 3 cases, and the excellent and good rate was 100% at last follow-up.
ConclusionThe iliac flap combined with anterolateral thigh flap for repair of the first metatarsal bone and large skin defect is a practical way with good shape at one stage.
Objective To study the method and effect of transferring the pedicled second metatarsal base for repairing bone defect of lateral malleolus. Methods Thirty lower limb specimens were anatomized to observe the morphology, structure and blood supply of the second metatarsal bone . Then transferring of thepedicled second metatarsal base was designed and used in 6 patients clinically.All cases were male, aged from 24 to 48 years old, and the area of bone defect was 3-4 cm. Results Followed up for 3-11 months, all patients healed primarily both in donor and recipient sites. There were excellent results in 4 cases and good results in 2 cases . The morphology and function of the malleoli were satisfactory. Conclusion Transferring of the pedicled second metatarsal base for repairing bone defect of lateral malleolus is an effective and reliable operative method.
In order to explore a new method to treat the ischemic necrosis of the head of 2nd metatarsal bone in adult, transposition of reversed vascularized metatarsal bone graft was adopted in the treatment of 4 cases, 2 of which were followed up for one and a half years. The postoperative X-ray showed the round head of the 2nd metatarsal bone became round and even density. The clinical observation showed that there was excellent function of metatarsophalangeal joint. It was concluded that the reversed vascularized metatarsal bone graft could provide a reliable blood supply and various osteogenic factors to the avascularized head of the metatarsal bone, and the operation could also debride the joint cavity and carry out decompression.
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.
ObjectiveTo compare the dorsiflexion osteotomy (DO) and implant arthroplasty (IA) in terms of clinical and radiographic outcomes for patients with advaced Freiberg disease.MethodsA clinical data of 25 cases of Freiberg disease, who were admitted between July 2012 and July 2016 and met selection criteria, was retrospectively reviewed. According to the Smillie classification, all patients were classified as stage Ⅳ-Ⅴ. Among them, 13 cases were treated with DO (DO group) and 12 cases were treated with IA (IA group). No significant difference was found between the two groups in gender, age, side of the affected metatarsophalangeal (MTP) joint, location, Smillie classification, disease duration, and preoperative visual analogue scale (VAS) score, range of motion of the affected MTP joints, and the American Orthopedic Foot and Ankle Society (AOFAS) score (P>0.05). Total costs for index admissions were compared between the two groups. Clinical outcomes were evaluated in accordance with the VAS score, AOFAS score, and the range of motion of the affected MTP joints.ResultsAll incisions of the two groups healed by first intention. The follow-up time was 12-30 months (mean, 17 months) in DO group and 12-24 months (mean, 16 months) in IA group. The total cost of index admission was significantly higher in IA group than that n DO group (t=2.742, P=0.011). The AOFAS scores, VAS scores, and range of dorsiflexion and plantar flexion at last follow-up were significantly improved when compared with preoperative value in the two groups (P<0.05). There was no significant difference in all indexes between the two groups (P>0.05). X-ray film examination showed that the osteotomy healed within 8-12 weeks (mean, 9.5 weeks) after operation in DO group. None of the patients experienced internal fixator and implant related complications postoperatively.ConclusionDO and IA can provide significant improvement in pain and motion of the MTP joints for advanced Freiberg disease. But the DO may be the more economical method.
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.
Objective To discuss the etiology, cl inical manifestation, imaging, staging, and treatment of bone necrosis of the second metatarsal head, the navicular bone, and the talus so as to provide more information for cl inical appl ication. Methods The related home and abroad l iterature concerning bone necrosis of the second metatarsal head, the navicular bone, and the talus in recent years was reviewed extensively. And the cl inical manifestation, imaging, staging, and treatment were summarized and analyzed. Results Bone necrosis of the second metatarsal head, the navicular bone, and thetalus were more closely related to the particular anatomy; the environmental and genetic factors also lead to such diseases. The cl inical presentation was typically local pain and swell ing around the joint, frequently with restricted joint motion in severe cases. Both radiographs and MRI were used to be the main criteria for diagnosis and staging of these diseases. According to different phases, conservative therapy was effective in treating osteonecrosis at early stage. While surgical treatments such as osteotomy, fixation, and arthrodesis were used in late-stage bone necrosis. Conclusion The current methods of treatment have achieved good effect, but long-term cl inical follow-up is needed and the new surgery should be further studied.
Objective To analyze the biomechanical changes of hallux valus after Swanson prosthesis-arthroplasty of the 1st metatarsophalangeal joint combined with osteotomy and bone grafting of the 1st metatarsal bone by three-dimensional finite element analysis, so as to provide data basis for studying the changes of foot morphology and physiological function after hallux valus correction surgery. Methods A 65-year-old female patient with severe hallux valus admitted in January 2013 was selected as the research object. The CT data of the right foot was obtained, and the three-dimensional finite element models before and after Swanson prosthesis-arthroplasty of the 1st metatarsophalangeal joint combined with osteotomy and bone grafting of the 1st metatarsal bone were established by Mimics10.01, Geomagic Studio, and ANSYS12.0 software. ANSYS 12.0 software was used for nonlinear static stress analysis, and the hallux valgus angle (HVA), the intermetatarsal angle (IMA), and the von Mises stress distributions of the forefoot plantar surface and the 1st to 5th metatarsal bones were observed before and after operation. ResultsThe HVA and IMA were 56.3° and 16.3° before operation and 9.2° and 9.8° after operation, respectively. Before operation, the stress on the forefoot was the largest in the 4th metatarsal head zone and the smallest in the 1st metatarsal head zone; the stress on the medial side of the forefoot was significantly smaller than that on the lateral side, and the center of forefoot pressure was located on the lateral side. After operation, the stress on the forefoot was the largest in the 1st metatarsal head zone and the smallest in the 5th metatarsal head zone; the stress on the lateral side of the forefoot was significantly smaller than that on the medial side, and the center of forefoot pressure was located on the medial side. Before operation, the stress of the 5th metatarsal bone was the largest, and the 1st metatarsal bone was the smallest. After operation, the stress of the 1st metatarsal bone was the largest, and the 4th metatarsal bone was the smallest. Conclusion Swanson prosthesis-arthroplasty of the 1st metatarsophalangeal joint combined with osteotomy and bone grafting of the 1st metatarsal bone can effectively correct hallux valgus and make HVA, IMA, and plantar pressure distribution close to normal. However, postoperative stresses of the 1st to 5th metatarsal bones elevate, which may lead to associated complications.
