Central Metatarsal Head-Neck Osteotomies: Indications and Operative Techniques

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Radiographic analysis

Radiographic analysis is the gold standard by which the metatarsal length pattern or parabola is determined. However, although much has been written about the length pattern between the first and second metatarsals [14], [15], [16], [17], [18], little has been written to establish what exactly a “normal” global metatarsal length pattern or parabola should consist of [19], [20], [21], [22]. Bojsen-Møller [19] conducted a mechanical study and determined that the most mechanically effective

Central metatarsal vascular anatomy

The vascular supply to the central metatarsals has been well established in several anatomic studies [23], [24], [25]. The arcuate artery, arising from the dorsalis pedis artery, sends dorsal metatarsal arteries through the intermetatarsal spaces over the dorsal interosseous muscles that produce a well-defined dorsal capsular network to each of the metatarsal-phalangeal joints. The dorsal capsular branches anastomose with each other and with the plantar capsular vessels to form a dense

Central metatarsal osteotomies

Since Meisenbach's [26] description of a midshaft central metatarsal osteotomy in 1916, more than 40 procedures and modifications have been described in the literature [27], [28], [29], [30], [31], [32], [33], [34]. These procedures include (1) partial or total plantar condylectomy, metatarsal head resection, and ray resection; (2) metatarsal head-neck shortening, dorsiflexory, peg-in-hole, and combined osteotomies; (3) midshaft shortening and dorsiflexory metatarsal osteotomies; and (4) base

Minimal incision (percutaneous) osteotomy

Minimal incision or percutaneous osteotomy of the central metatarsals has received little attention in the literature [28]; however, this a valuable procedure for treating multiple central metatarsal deformities following iatrogenic injury, trauma with malunion, or plantar diabetic neuropathic ulcerations recalcitrant to healing or recurrent despite appropriate conservative measures (Lowell Scott Weil, Sr., DPM, personal communication, 2001).

The surgical technique begins with the patient

Weil metatarsal osteotomy

The Weil metatarsal osteotomy has received much attention in the medical literature regarding central metatarsal abnormalities (metatarsalgia, intractable plantar keratotic lesions, crossover second-toe deformity, length abnormalities, rheumatoid joint salvage, medial, and lateral lesser digit angulation at the metatarsal-phalangeal joint level) [33], [35], [36], [37], [38], [39], [40], [41], [42], [43], [44], [45] and has even been applied to the hand for metacarpal deformities [46]. The Weil

Telescoping metatarsal osteotomy

The “telescoping” metatarsal osteotomy is a novel procedure and is indicated in the presence of an abnormal central metatarsal length pattern (James B. Ringstrom, DPM, personal communication, 1997) (Fig. 3A). This central metatarsal osteotomy involves minimal soft tissue dissection, is easy to perform, and allows for precise shortening but is inherently unstable and requires a period of protected partial weight bearing to avoid hardware failure and resultant complications.

The surgical technique

Concomitant lesser digit procedures

Lesser digital procedures performed concomitantly with central metatarsal osteotomies involve sagittal or transverse plane deformity correction through the use of a (1) proximal interphalangeal joint arthrodesis [7], [8], [50]; (2) flexor digitorum longus tendon transfer (see references [5], [6], [51], [52]); (3) extensor digitorum brevis tendon transposition [53]; (4) min-Akin (Akinette) osteotomy of the base of the proximal phalanx [54]; or (5) metallic hemi-implant (resurfacing

Summary

Various central metatarsal osteotomies at the head-neck level have been described in the medical literature, with this article focusing on the minimal incision osteotomy, Weil metatarsal osteotomy and its modifications, and the telescoping metatarsal osteotomy. The indications, surgical techniques, postoperative care, and literature available for each osteotomy have been presented in detail. The use of ancillary lesser digit procedures to aid in sagittal and transverse plane deformity at the

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