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Ravashanov Shavkat, the junior scientific researcher, department of adolescents orthopedics, Scientific Research Institute of Traumatology and Orthopedics of the Ministry of Health of the Republic of Uzbekistan E-mail: sixatfarm@mail.ru
Oallus distraction for congenital fourth brachymetatarsia
Abstract: 22 metatarsal lengthening procedures by callus distraction using mini-fixator were performed in 15 patients with congenital fourth brachymetatarsia. The mean age at the time of the surgery was 16.3 years (range, 11-28 years). The mean duration of follow-up was 1.3 years (range, 6 months-2.0 years). The bones were lengthened at a rate of 1.0 mm/day by a mean of 17.8mm (range, 11-22 mm), which was 37.7% of their original length (range, 33.3-53.6%). The mean healing index was 52.8 days/cm (range, 39-68.7 days/cm). In all cases we achieved the restoration of metatarsal parabola, most patients satisfied with the result of surgery. The evaluation according to AOFAS score was excellent in 20 cases and good in 2 cases. The most common complication was stiffness of the metatarsophalangeal joint (5) and hypertrophic scarring (2), premature consolidation (1) and dislocation of finger (1). Distraction osteogenesis for fourth brachymetatarsia can give satisfactory cosmetic and functional results. Most complications can be treated effectively and succes sfully even though additional surgery may be warranted.
Keywords: brachymetatarsia, Callus distraction, external fixator, complication.
Introduction
Congenital brachymetatarsia is an abnormal shortness of the metatarsal bones due to a premature closure of the epiphyseal plate. It may be congenital, post-traumatic, or iatrogenic, or the disease can be associated with such systematic diseases [2-7]. This condition affects one, usually the fourth, or more metatarsals, unilaterally or bilaterally [1-11]. Compliments ofpatient are the dorsally displacement of digit, metatarsalgia, shoe irritation, tyloma formation and deformation of adjacent fingers (hallux valgus, varus of fifth finger) [2; 4; 5; 6]. The main option of surgical correction is restoration of metatarsal and finger parabola.
Two surgical methods: one-stage lengthening or distraction osteogenesis is widely used. Each method has its own advantages and disadvantages. The advantages of one-stage lengthening include a shorter period of bony union, better patient compliance, and less scar formation. However, this method has the disadvantages of donor site morbidity, neurovascular impairment, and smaller length gain. The advantages of distraction osteogenesis include: no need for
bone grafting, easier tendon stretching, fewer neurovascular complications, early weight bearing, and a larger length gain, whereas disadvantages include stiffness or subluxation of the metatarsophalangeal (MTP) joint, cavus or angulation deformity, pin tract infection, and a longer period of bony union [1; 3; 7; 9].
The purpose ofthis study was to review the results oftreatment 15 patients with congenital fourth brachymetatarsia, for whom a total of 22 gradual lengthening procedures were performed by callus distraction using external fixator which was designed by the author.
Patients and methods
Between 2013 and 2016 at Scientific Research Institute of traumatology and orthopedics, Tashkent, Uzbekistan, 14 girls and one boy underwent 22 fourth metatarsal lengthening procedures by callus distraction. The mean age at the time of the surgery was 16.3 years (range, 11-28 years). The mean duration of follow-up was 1.3 years (range, 6 months-2.0 years). All the patients complained of finger shortening and the cock-up deformity, pain on walking, 4 patients had hallux valgus. 5 patient had bilateral, 5 -left sided and
5-right sided brachymetatarsia. 1 patient underwent bilateral fourth metatarsal lengthening, the others — one-side by turns.
Operative technique
Under tourniquet hemostasis, a linear longitudinal incision was made on the dorsum of the fourth metatarsal. The extensor tendons were retracted and the metatarsal was exposed. After drill holes were made, four pins with 3mm diameter shafts were inserted in line, perpendicular to long axis of the metatarsal. Two proximal pins were inserted to the proximal metaphysis of the metatarsal, and two distal pins to the distal metaphysis of the metatarsal. The periosteum was longitudinally incised and carefully stripped. A transverse osteotomy between the second and third pins was made using an osteotom. The external fixator was attached. Metatarsophalangeal joint fixated with Kirschner wire transnarticularly. The periosteum and skin were sutured. Elongation of the extensor tendon was performed in cases, where metatarsal shortening exceed 20 mm. After 5 days, callus distraction was started at a rate of 1 mm/day. The patients performed distraction by themselves as outpatients. Full weight bearing was allowed after restoration of metatarsal and toe tip parabola. K-wire removed after 2 weeks restoration. Radiographs were checked every other week to inspect the degree of osteogenesis and joint condition. When bone consolidation was confirmed by radiographs, the fixator was removed.
Results
We evaluated fourth metatarsal lengths, lengthening gains and treatment period (day), lengthening index, and ranges of motion of first MTP joints. We defined stiffness as being restriction of MTP joint motion to <30°. The outcome was assessed clinically according to the American Orthopedic Foot and Ankle Society (AOFAS) hallux scale and graded as excellent (> 85), good (71-85), fair (56-70), or poor (< 56).
Bone consolidation was completed in all cases. Non-union and neurovascular complications were not observed in any of the patients. The metatarsal bones were lengthened by mean of 17.8mm (range, 11-22 mm), which was 37.7% of their original length (range, 33.3-53.6%). The mean healing index was 52.8 days/cm (range, 39-68.7 days/cm). In all cases we achieved the restoration of metatarsal parabola, most patients satisfied with the result of surgery. The evaluation according to AOFAS score was excellent in 20 cases and good in 2 cases. At early postoperative t follow-up (3 month),
5 patients had stiffness of the metatarsophalangeal joint. Joint stiffness was gradually resolved after the physiotherapeutic procedures. 2 patients complained to hupertrophic scarring. Dislocation of the metatarsophalangeal joint was observed in one case in which inadequate transarticular fixation with K-wire were performed. We recommend fixating the phalanx to metatarsal with K-wire at least to 10mm. Because, in congenital brachymetatarsia the head of metatarsal is osteoporotic, and it cannot fixate adequately. But patient refused of surgical treatment of dislocation. Premature consolidation occurred in one patient, because of wrong rate distraction. We performed reosteotomy and continued distraction. No pin-tract infection, angular deformation, non-union revealed.
Discussion
The main advantages of gradual lengthening by callus distraction are that there is no need for bone grafting, there are fewer neurovascular complications, and there is the capability of early weight bearing. The principal problems in metatarsal lengthening by callus distraction are joint stiffness and subluxation of the metatarsophalangeal joint [3-11]. These are considered to be due to the resistance of tendons and adjacent connections such as the transverse metatarsal ligament, flexor sheath, and other soft tissue structures. Masada et al. [7] and Takakura et al. [9] reported that the amount of lengthening should not exceed 40% of the original length in order to prevent joint stiffness and subluxation. Elongation of the tendon or temporal metatarsophalangeal joint fixation with Kirschner wire has also been recommended [6, 11]. In 10 of our 22 metatarsal lengthening procedures, the amount of lengthening exceeded 40% of the original length. In one case occurred the metatarsophalangeal joint dislocated due to inadequate transarticular fixation with K-wire. Our distraction rate was also 1.0 mm/day, and joint stiffness were observed in 5 cases. We recommend elongation of extensors if the shortening of metatarsal exceeds 20 mm. Although these problems were gradually resolved in our series. All our major complications (dislocation and premature consolidation) were associated with technical operative and postoperative managements.
Distraction osteogenesis for fourth brachymetatarsia can give satisfactory cosmetic and functional results. Most complications can be treated effectively and successfully even though additional surgery may be warranted.
Fig. 1. Pre-operative photographs and AP radiograph of a 14-year-old girl with brachymetatarsia of the 4th metatarsal of the right foot
Fig. 3. Post-operative (18 month) photographs and radiographs
Post-operative (6 month) photograph of a 14-year-old girl with hypertrophic scarring. bilateral brachymetatarsia of the 4th metatarsals complicated with
References:
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2. Bartolomei F.J. Surgical correction ofbrachymetatarsia. J. Am Podiatr Med Assoc. 1990; 80: 76-82.
3. Choi I. H., Chung M. S., Baek G. H., et al. Metatarsal lengthening in congenital brachymetatarsia: one stage lengthening versus lengthening by callotasis. J. Pediatr Orthop. 1999; 19: 660-664.
4. Fox I. M. Treatment of brachymetatarsia by the callus distraction. J. Foot Surg 1998; 37: 391-395.
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6. Magnan B., Bragantini A., Regis D., Bartolozzi P. Metatarsal lengthening by callotasis during the growth phase. J. Bone Joint Surg Br 1995; 77: 602-607.
7. Masada K., Fujita S., Fuji T., et al. Complications following metatarsal lengthening by callus distraction for brachymetatarsia. J. Pediatr Orthop. 1999; 19: 394-397.
8. Scher D. M., Blyakher A., Krantzow M. A modified surgical techniqwwue for lengthening of a metatarsal using an external fixator HSSJ (2010) 6: 235-239.
9. Takakura Y., Tanaka Y., Fujii T., Tamai S. Lengthening of short great toes by callus distraction.J. Bone Joint Surg Br 1997; 79 B: 955-958.
10. Urano Y., Kobayashi A. Bone lengthening for shortness of the fourth toe. J. Bone Joint Surg Am. 1978; 60:91 Y 93.
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Rasulov Ulugbek Abdugafurovich, Central Military Hospital of the Ministry of Defense of the Republic of Uzbekistan, Head surgeon Ministry of Defense of the Republic of Uzbekistan.
E-mail: uli4-67@mail.ru
Oonservative treatment and rehabilitation of the patients with occlusive disease of femoropopliteal segment
Abstract: 48 patients who underwent reconstructive surgery in the femoral-popliteal-tibial segment are divided into 2 groups were under the watchful and received a course of rehabilitation therapy and have not received this treatment. After 2 years it noted that in one group the number of positive results for the treatment of above 45%, and the mortality rate is 25% lower than in group 2.
Keywords: antithrombotic prophylaxis, femoral-popliteal-tibial segment, rehabilitation, medical therapy.
The relevance of the research. The main site oflocalization of occlusive arterial lesions, leading to the loss of a limb, is the femoropopliteal segment — shin [1, 5-9; 2, 137-138; 4, 113; 5, 41-44]. Surgical treatment of such patients gives better results than conservative therapy. Nevertheless, conservative therapy is an essential complement to the adequate treatment of patients with obliterating vascular disorders of the lower limbs in the preoperative and in the postoperative period.
The debate continues on the choice of a rational conservative therapy and optimal antithrombotic prophylaxis in the complex postoperative rehabilitation of patients after revascularization of the limb [3,118-120; 6, 204; 7, 80-82].
Purpose of the study. Improved results of treatment of patients with occlusive-stenotic lesions in the infrainguinal segment targeted by antithrombotic prophylaxis and full rehabilitation of patients.
Materials and methods of research. We studied the role of the clinical examination of patients discharged from hospital after proximal femoral-popliteal bypass grafting, through a comparative analysis of two groups of patients in terms of mortality and the number of amputations, depending on the quality of post-operative rehabilitation and dispensary observation.
The first group included 26 patients who were successfully operated in the vascular suit. All patients in this group shortly after surgery were under outpatient observation of angiosurgeon. After 0.5, 1, 2 and 3 years, the patients were examined, including the ul-
trasound investigation, and haemorrheology indicators, lipid and carbohydrate spectrum. Twice a year, the patient went through a course of conservative therapy.
Basic principles of treatment of lower limb ischemia were as follows: 1. Correction of risk factors:
a) cessation of smoking,
b) strict control of plasma lipid levels,
c) control of blood pressure,
d) therapy, which reduces the level of lipids.
2. Exercise and training:
a) a special program of training,
b) walking on 45-60 min 3 times per week (12 weeks),
c) adding 6.5 min training walk every 6 months (before the pain).
3. Drug therapy:
a) intravenous infusion of reosorbilakt, latran, tivortin 10 days, twice a year. Subsequently, in the outpatient setting, patients received aspirin (100 mg per day) for two months, then along with aspirin sequentially sulodexide 250 LU twice a day for two months;
Further, in a month,
b) inhibitors of fosfodiesterazes- cilostazol 100 mg per day for a month.
c) physiotherapy — massage of the lower limbs, applications with paraffin wax (ozokerite) to pelvis and thigh.
The second group (control) consisted of 22 patients who, after discharge from the hospital for various reasons (mostly nonresident)
