Atilio Migues

Floating-Toe Deformity as a Complication of the Weil Osteotomy

Background: The Weil osteotomy for treatment of central metatarsalgia is an oblique osteotomy of the metatarsal neck and shaft parallel to the ground that provides controlled shortening of the metatarsal without additional depression. It offers many advantages over more traditional osteotomies, including stability and a large area of bone-to-bone contact. However, a floating-toe deformity appears to be a common complication after this osteotomy. Methods: Between February, 2000 and February, 2003, 70 Weil osteotomies (in 26 patients) were done at one institution. Follow-up averaged 18.3 (6 to 36) months. Weightbearing radiographs were examined for shortening, subluxation, and for evidence of nonunion or malunion of the metatarsal head. Floating-toe deformity and mild recurrent tenderness were noted in the history and physical examination. The American Orthopaedic Foot and Ankle Society (AOFAS) Lesser Metatarsophalangeal-Interphalangeal Scale (LMIS) was used for outcome rating. At final follow-up, nonunion and malunion also were evaluated. Results: The median score of the AOFAS scale was 81 (19 to 95) points. Fifty-four percent of the osteotomies were done with a proximal interphalangeal (PIP) joint arthrodesis of the same ray, and we observed a higher occurrence of floating-toe deformity in this group of patients. Conclusion: Although it may be associated with some complications, the Weil osteotomy is an effective and safe procedure for the treatment of central metatarsalgia. We conclude that floating-toe deformity is a common complication associated with PIP joint arthrodesis. Although it appears not to cause a functional impairment, concurrent PIP arthrodesis should be avoided to reduce the occurrence of floating toes.

Stress Fracture Nonunion at the Base of the Second Metatarsal in a Ballet Dancer A Case Report

Stress fractures are defined as spontaneous fractures of normal bone that are the result of repetitive stresses that are themselves harmless. Although the metatarsal shaft is the most common location of a stress fracture in the general population, the base of the second metatarsal is by far the most common site in ballet dancers. Few series published in the orthopaedic literature report a quick recovery of this fracture after conservative treatment, and cases of nonunion have not been previously reported. We report a nonunion at the base of the second metatarsal, secondary to a stress fracture, in a 24-year-old professional ballet dancer with successful outcome after surgical repair.

Repair of Talar Neck Nonunion with Indirect Corticocancellous Graft Technique: A Case Report and Review of the Literature

In this article, a case of talar neck fracture nonunion is presented. Union was accomplished with an indirect placement of a corticocancellous fibular graft through a posterolateral approach. The advantages and indications for this method of the treatment of talar neck nonunion are discussed, together with a review of the literature.

Case Reports: Symptomatic Bilateral Talonavicular Coalition

Congenital talonavicular coalition is reported less frequently than talocalcaneal or calcaneonavicular coalition and represent approximately 1% of all tarsal coalitions. Although reportedly transmitted as an autosomal-dominant disorder, tarsal coalition may be inherited as an autosomal-recessive trait. It has been associated with various orthopaedic anomalies, including symphalangism, clinodactyly, a great toe shorter than the second toe, clubfoot, calcaneonavicular coalition, talocalcaneal coalition, and a ball-and-socket ankle. Patients with talonavicular coalitions are usually asymptomatic and rarely undergo surgical treatment. We report the case of a 24-year-old woman with symptomatic bilateral talonavicular coalitions and previously unreported associated anomalies (nail hypoplasia and metatarsus primus elevatus) and review the relevant literature. The patient underwent surgery (calcaneocuboid joint distraction arthrodesis and a proximal plantar flexion osteotomy with a dorsal open wedge of the first metatarsal). At 1-year followup, she was pain-free with better alignment of both feet and showed radiographic consolidation of the arthrodesis. Although this condition is less likely to be clinically important than other tarsal fusions, it sometimes can be painful enough for the patient to undergo surgery.

Minimally Invasive Surgery in Hallux Valgus and Digital Deformities

Minimally invasive surgical techniques are an alternative with potential advantages in the treatment of forefoot deformities.

Endomedullary Screw Fixation for First Metatarsophalangeal Arthrodesis

Background: The purpose of this study was to evaluate the clinical and radiological results in a group of patients who underwent first metatarsophalangeal joint arthrodesis with an endomedullary screw fixation technique (MPA-E). Methods: Between 2003 and 2009, 101 metatarsophalangeal arthrodesis were performed in 76 patients. There were 64 women and 12 men with an average age of 68 years. The indication for surgery was osteoarthritis with severe pain and functional limitation. Patients were evaluated radiologically and with the American Orthopaedic Foot & Ankle Society scoring system (AOFAS) at an average follow-up of 32 months (range, 24-92 months). Results: The success rate was 93%, with an increase of the average preoperative AOFAS from 38.5 points to 85.5 points postoperatively (P < .0001). The consolidation rate after radiological evaluation was 90.1%; there were 5 cases (5.0%) with asymptomatic nonunion and 5 cases (5.0%) with poor results because of symptomatic nonunion. Screw removal was needed in 4 feet (4.0%), and 2 feet (2.0%) had acute postoperative superficial infection. No implant cutout was observed. Conclusion: The MPA-E technique provided consistent and high functional outcomes. This valid and effective alternative should be considered as an option for hallux metatarsophalangeal arthrodesis. Level of Evidence: Level IV, retrospective case series.

Joint-preserving procedure for moderate hallux rigidus.

Hallux rigidus is a complex disorder, and numerous surgical procedures have been described for its management. Although the optimal technique has yet to be defined, it is important to individualize the degree of arthritis as well as other clinical features (metatarsal index, pain characteristics, and so forth) of each patient to achieve optimal results. The authors firmly believe that for patients with only dorsal pain, a cheilectomy is the ideal choice because good and reliable results can be achieved. When pain is also present around the joint or is combined, which is the most common scenario, their main choice now is to perform a decompressive osteotomy. The biomechanics of the joint are more adequately restored, soft tissues are relaxed, and remodeling of the contracted tissues is allowed. More investigation has still to be performed to elucidate the origin of this abnormality.