A 12-year-old Saluki was presented with acute lameness and plantar swelling of the right metatarsus following an episode of free running. Radiographs showed soft tissue swelling only, the involved bone and joint structures were unremarkable. The lesion recurred several months later. Ultrasonographic imaging of the lesion revealed a well-vascularized cavernous structure. Subsequent surgical removal and histopathological examination of the structure raised the initial suspicion of an arteriovenous fistula, which was then confirmed histologically following a second surgical removal of another recurrence. The purpose of this case report is to illustrate the potential complexity of what initially appears to be a simple lameness. At the same time, attention is focused on the possibility that arteriovenous fistulas may tend to recur.
Ein 12 Jahre alter Saluki wurde mit einer akuten Lahmheit und plantaren Schwellung des rechten Metatarsus nach dem Freilauf vorgestellt. Im Röntgen war lediglich eine Weichteilschwellung zu erkennen, die beteiligten Knochen- und Gelenkstrukturen zeigten sich unbeteiligt. Einige Monate später kam es zum Rezidiv der Schwellung. Bei der diesbezüglich durchgeführten Ultraschalluntersuchung war eine gut vaskularisierte kavernöse Struktur zu erkennen. Die folgende operative Entfernung und histopathologische Untersuchung der Struktur ergab den ersten Verdacht auf eine arteriovenöse Fistel, welche sich auch bei einer zweiten operativen Entfernung nach einem weiteren Rezidiv histologisch bestätigte. Der vorliegende Fallbericht soll die mögliche Komplexität einer zunächst einfach zu behandelnden Lahmheit darstellen. Gleichzeitig liegt das Augenmerk auf der Möglichkeit, dass arteriovenöse Fisteln zu Rezidiven tendieren können.

BACKGROUND: Surgical treatment for Freiberg disease (also known as avascular necrosis of the metatarsal head) has not been completely defined. This retrospective study evaluated short-term outcomes after arthroscopic treatment of Freiberg disease.
METHODS: From 2015 to 2019, 13 patients (15 feet) diagnosed as having Freiberg disease were enrolled for arthroscopic surgery. Feet were divided based on the Smillie classification system (two with stage I, eight with stage II, three with stage III, one with stage IV, and one with stage V). Arthroscopic interventions, including synovectomy, debridement, chondroplasty, microfracture, and loose body removal, were performed without considering the Smillie classification stage. Radiologic outcomes were evaluated by radiography (preoperatively and 3, 6, and 12 months postoperatively) and magnetic resonance imaging (preoperatively and 12 months postoperatively). Clinical outcomes were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) lesser metatarsophalangeal (MTP)-interphalangeal score and the visual analog scale (VAS) score. The MTP joint range of motion was measured using a goniometer preoperatively and postoperatively.
RESULTS: Radiologic studies showed no evidence of osteonecrosis progression in postoperative 12-month radiographs of any patients. Postoperative 12-month magnetic resonance images showed reduction of bone marrow edema, irregularity of subchondral bone, and cartilage defects in all patients. Significant improvements in AOFAS and VAS scores occurred at all postoperative time points compared with preoperative scores (P = .001). The MTP joint range of motion also showed improvement at last follow-up (P = .001).
CONCLUSIONS: Arthroscopic surgery for Freiberg disease showed excellent clinical outcomes, MTP joint range of motion, and short-term outcomes regardless of stage (Smillie classification) in radiologic evaluation.

Atypical fractures are well elucidated when they occur in the femur and are related to the use of bisphosphonates. Prolonged therapy with this drug leads to excessive suppression of bone remodeling, which makes the bone more brittle. In general, they are caused by minimal trauma or are atraumatic. This type of fracture is also reported in other bony sites, such as the metatarsus. Some reports and studies on atypical metatarsal fractures have been published, but further investigations are required to better understand this type of fracture and establish the proper diagnosis, treatment and conduct. The present study is a report of five cases of patients who presented metatarsal fractures during therapy with bisphosphonates. All patients were female, had osteoporosis as a preexisting disease, were taking bisphosphonates, presented fractures that were either atraumatic or caused by minimal trauma, and the imaging examination showed a transverse meta-diaphyseal fracture of the fifth metatarsal shaft with thickening of the lateral cortex, image characteristics similar to the criteria used by the American Society for Bone and Mineral Research (ASMBR) to define atypical femur fractures.

BACKGROUND: The global number of people with diabetes is estimated to reach 643 million by 2030 of whom 19-34% will present with diabetic foot ulceration. Insoles which offload high-risk ulcerative regions on the foot, by removing insole material, are the main contemporary conservative treatment to maintain mobility and reduce the likelihood of ulceration. However, their effect on the rest of the foot and relationship with key gait propulsive and balance kinematics and kinetics has not been well researched.
OBJECTIVE: The aim of this study is to investigate the effect of offloading insoles on gait kinematics, kinetics, and plantar pressure throughout the gait cycle.
METHODS: 10 healthy subjects were recruited for this experiment to walk in 6 different insole conditions. Subjects walked at three speeds on a treadmill for 10 minutes while both plantar pressure and gait kinematics, kinetics were measured using an in-shoe pressure measurement insole and motion capture system/force plates. Average peak plantar pressure, pressure time integrals, gait kinematics and centre of force were analysed.
RESULTS: The average peak plantar pressure and pressure time integrals changed by -30% (-68% to 3%) and -36% (-75% to -1%) at the region of interest when applying offloading insoles, whereas the heel strike and toe-off velocity changed by 15% (-6% to 32%) and 12% (-2% to 19%) whilst walking at three speeds.
CONCLUSIONS: The study found that offloading insoles reduced plantar pressure in the region of interest with loading transferred to surrounding regions increasing the risk of higher pressure time integrals in these locations. Heel strike and toe-off velocities were increased under certain configurations of offloading insoles which may explain the higher plantar pressures and supporting the potential of integrating kinematic gait variables within a more optimal therapeutic approach. However, there was inter-individual variability in responses for all variables measured supporting individualised prescription.

The variability of movement plays a crucial role in shaping individual\'s gait pattern and could, therefore, potentially serve diagnostic purposes. Nevertheless, existing concepts for the use of variability in diagnosing gait present a challenge due to the lack of adequate benchmarks and methods for comparison. We assessed the individuality of contribution of foot parts that directly mediate the transmission of forces between the foot and the ground in body weight shifting during walking based on 200 pedobarometric measurements corresponding to the analysed foot parts for each of 19 individuals in a homogeneous study group. Our results show a degree of individualisation of the contribution of particular foot parts in the weight-shift high enough to justify the need to consider it in the diagnostic analysis. Furthermore they reveal noticeable, functionally driven differences between plantar areas most apparent between the lowest individuality for the first foot ray and the highest for second one and metatarsus. The diagnostic reference standard in pedobarometry should describe the contribution in the shift of body weight during walking for each area of the foot separately and include information on the intra-individual variation and individualisation of descriptors of the contribution. Such a comprehensive standard has the potential to increase the diagnostic value of pedobarometry through enrichment of the assessment description.

Bunionette deformity (BD) is a painful condition of the fifth metatarsal characterized by an osseous prominence and fifth toe varus deformity. The purpose of this study is to assess the clinical, functional, and radiographic outcomes of percutaneous distal metatarsal metaphyseal osteotomy (DMMO) without fixation or postoperative strapping of the foot.
A retrospective case series was performed on 111 patients (132 feet) with symptomatic BD who underwent percutaneous DMMO of the fifth metatarsal from September 2020 to January 2022 by an experienced minimally invasive surgeon. According to the Shimobayashi classification, we treated 1 type I deformity, 37 type II deformities, 52 type III deformities, 42 feet with type IV deformity, and no patient with a type V deformity. Ninety patients (81%) underwent unilateral osteotomy, and 21 (19%) had bilateral osteotomies. Most cases included other procedures including treatment of 114 associated deformities of the same feet: 68 bunions, 12 lesser metatarsal osteotomies (2-3-4 metatarsals), and 34 hammertoes (20 second hammertoes, 10 third hammertoes, 1 fourth hammertoes, 2 fifth hammertoes). Patient-reported clinical outcome measures, including the Foot Function Index (FFI) questionnaire, the visual analog score (VAS), and overall satisfaction were collected. Fourth-to-fifth intermetatarsal angle (IMA) correction, time to bone union, and complication rates were assessed in all patients.
Mean follow-up was 24.1 months (range, 14-39 months). Both radiographic parameters and patient-reported outcome measures significantly improved after DMMO procedure. The average fourth-to-fifth IMA improved from 12.2 degrees, preoperatively, to 4.4 degrees, postoperatively (P < .001). Patient outcomes reflect the overall outcomes of the combined surgeries on a per-patient basis. Preoperatively, patients had a mean VAS score of 7.6, which improved to 0.6 at the last follow-up (P < .001). Furthermore, the average FFI significantly decreased from pre- to postoperation from 19.2 to 4.4, respectively (P < .001). Overall, 108 of 111 patients reported being satisfied with the outcomes of the procedure. Average bone union was achieved at 12.6 weeks postoperation, with a minimum of 12 and a maximum of 25 weeks. The complication rate was 1.5%, including 1 case of an asymptomatic cock-up deformity and 1 case of lateral fifth metatarsal shaft bone overhang pain, which resolved with an exostectomy.
The results of this study of patients who had minimally invasive surgery from an experienced surgeon suggest that percutaneous DMMO of the fifth metatarsal without internal fixation or postoperative immobilization or strapping can be effective at improving radiographic alignment, pain, function, and overall satisfaction with minimal rates of complication.
Level IV, case series.

BACKGROUND: Treatment for Freiberg\'s disease is largely conservative. For severe disease and refractory cases, there are various surgical options. The purpose of this study was to report the 5-year clinical outcomes of a modified Weil osteotomy in the treatment of advanced Freiberg\'s disease.
METHODS: Twelve patients (12 feet), with a mean age of 30.7 years (range 17-55), were treated with synovectomy and modified Weil osteotomy of the affected distal metatarsal head. There were 10 females and 2 males. Clinical outcomes were independently evaluated pre and postoperatively using the American Orthopaedic Foot and Ankle Society (AOFAS) scoring system and a subjective satisfaction score. Radiological union was evaluated postoperatively. Nine (75%) feet involved the 2nd metatarsal and 3 feet (25%) involved the 3rd metatarsal. According to the Smillie classification, 6 feet were Grade IV and 6 feet were grade V.
RESULTS: No patients were lost to follow up and the mean follow-up time was 5.2 years (4-7). AOFAS scores improved from 48.1 + /- 7.4-88.9 + /- 10.1 postoperatively giving a mean improvement of 40.8 (p < 0.001). In total, 92% of patients were satisfied with their operation at latest follow-up, reporting excellent or good results. All patients had postoperative radiological union. One patient had a superficial postoperative infection that was successfully treated with oral antibiotics.
CONCLUSIONS: Modified Weil osteotomy is an effective treatment for advanced Freiberg\'s disease with good outcomes and few complications.

BACKGROUND: The aim of this study was to compare the clinical, functional and radiographic outcomes in patients who underwent the original Lapidus procedure (OLP) with fusion and undesired non-fusion between the first (M1) and second (M2) metatarsals.
METHODS: A retrospective and comparative analysis of 29 patients (38 feet) who underwent the OLP was performed. They were divided in two groups: (1) 23 feet in which fusion occurred and (2) 15 with undesired non-fusion. Clinical and functional data were assessed with the VAS for pain, AOFAS, LEFS and SF-12. SF-12 comprises physical and mental health scales (PCS-12 and MCS-12). Radiographic parameters assessed were bony and soft tissue forefoot widths (BSFW), intermetatarsal-angle (IMA) and HV-angle (HVA).
RESULTS: Separately, the groups presented significant improvements in all questionnaires (p < 0.001), except on MCS-12 (fusion p = 0.08 and non-fusion p = 0.27). When comparing both groups, patients with fusion had higher AOFAS scores (p < 0.05). Both groups presented the same improvements on BSFW, IMA and HVA (p = 0.09, p = 0.16, p = 0.52 and p = 0.63).
CONCLUSIONS: Excellent results were observed, even when without fusion between M1 and M2. Patients who evolved with fusion between the M1 and M2 showed greater improvements in the AOFAS score.
METHODS: III, retrospective comparative study.

Delivery of mesenchymal stem cells (MSC) via intravascular techniques to treat diffuse and/or inaccessible soft tissue injuries has grown in popularity. The purpose of the current prospective, analytical pilot study was to utilize CT to validate this novel technique and provide additional evidence to support its use for injectate delivery to specific soft tissue structures. Of particular interest was the proximal suspensory ligament, which presents a challenging injection target. Six adult horses without lameness underwent CT of the distal hindlimbs. Scans were obtained prior to ultrasound-guided catheterization of the cranial tibial artery, in addition to early and delayed scans acquired following intra-arterial contrast administration. Region of interest analysis of the superficial and deep digital flexor tendons and suspensory ligament was used to assess contrast enhancement within these structures. Linear mixed models were used to determine statistical significance. Significant (P < 0.05) mean contrast enhancement was seen in all postinjection time points in all soft tissue structures of interest. This indicates that ultrasound-guided injection of the cranial tibial artery results in perfusion of injectate throughout the distal hind limb, including the major soft tissue structures of the metatarsus. This provides further support for this technique as a method of MSC delivery to multifocal or inaccessible injury of these structures, including the proximal suspensory ligament.

An excess of body weight can produce morphological changes in the feet of children. The aim of this study was to assess the morphological differences of the foot in children based on their body mass index and to determine the risk factors for the development of a hallux valgus in childhood and adolescence. One Thousand Six Hundred Seventy-Eight children (5-17 years) were classified as group with obesity, overweight, and normal weight. Lengths, widths, heights and angles of both feet was measured with a 3D scanner. The risk of developing hallux valgus was calculated. Group with overweight and obesity presented longer feet (p = 0.00), wider metatarsals (p = 0.00) and wider heels (p = 0.00). Arch height was lower (p > 0.01) in the group with obesity, and the hallux angle was greater in the group with normal weight (p < 0.05). The relative risk of a lateral hallux deviation increases with age, foot length and heel width (Exp (B) > 1). Children with overweight and obesity had longer and wider feet. The arch height was higher in children with overweight, and lower in children with obesity. Age, foot length, and heel width could be risk factors for the development of hallux valgus, while metatarsal width and arch height could be protective factors. Monitorization of the development and characterization of the foot in childhood as a clinical tool could help professionals to early identify the patients presenting risk factors and prevent future deformities and other biomechanical conditions in adulthood by implementing protecting measures.