Brachymetatarsia

Metatarsal lengthening by distraction osteogenesis for brachymetatarsia in paediatric patients: is it safe and effective?

PURPOSE

The primary aim is to assess the efficacy of the surgical callus distraction technique of the metatarsus in paediatric patients. Secondary objectives are to assess complications and treatment duration. We have also described the details of our surgical technique.

MATERIALS AND METHODS

A case series review of paediatric patients who had metatarsal lengthening at our unit between 2014 and 2022. Patient demographics, duration of time in frame, complications and metatarsal length achieved were recorded. The AOFAS Midfoot and the MOXFQ were taken pre-operatively and at final follow-up.

RESULTS

Sixteen metatarsals in 8 patients (14 feet) underwent lengthening between 2014 and 2022 using the MiniRail OrthoFix 100 (Orthofix Medical Inc, Lewisville, TX, USA). The mean age was 13.3 (12-17) years. The average duration between surgery and implant removal was 5.2 months. According to Paley's classification, there was one obstacle encountered in a patient who required a revision of their osteotomy and one problem in another patient who had an infected metatarsophalangeal joint stabilising k-wire treated with oral antibiotics. The Mean AOFAS Midfoot score improved from 53.10 to 86.40 (p < 0.0001) and the Mean MOXFQ improved from 32.5000 to 12.1250 (p < 0.05); these were statistically significant.

CONCLUSION

Gradual metatarsal lengthening using the MiniRail external fixator is a safe and effective method to treat brachymetatarsia in paediatric patients. This preliminary report describes and supports metatarsal lengthening in appropriate patients. Holistic care in terms of a pre-operative assessment, psychological support and preparation for the extended rehabilitation period are vital.

Comparing Outcomes of Acute Versus Gradual Surgical Correction in Brachymetatarsia

Brachymetatarsia consists of a shortened metatarsal resulting in a shorter toe. Pain with shoe wear and cosmetic concerns are the main reasons for surgical intervention. Surgical techniques to increase metatarsal length include acute lengthening with interpositional bone grafting or gradual lengthening with callus distraction. We performed a retrospective cohort study for 1 surgeon's patients at 1 institution over 10 years. Twenty-nine feet in 22 patients met inclusion criteria for acute correction; 16 feet in 11 patients were included for gradual correction. Mean ages were 26.3 ± 12.1 and 27 ± 10.8 in the acute and gradual groups, respectively (p = .79). Most patients were female: 95.4% of acute cases and 90.1% of gradual cases. Most involved lengthening the fourth metatarsal: 86.7% and 100% of acute and gradual groups, respectively (p = .54). Correction obtained amounted to 14.4 ± 2.97 mm (range, 10-22 mm) in acute cases and 14.8 ± 2.39 mm (range, 10-20 mm) in gradual cases (p = .81). The mean percent increase in metatarsal length was 21.1 ± 14% for acute and 22.6 ± 12.4% for gradual (p = .72). Mean consolidation was 8.9 ± 2.51 weeks for acute and 21.4 ± 10.8 weeks for gradual (p = <.001). Nonunions were most common in the gradual group (37.5%) with need for more revisional surgery (43.5%) compared with the acute group; both were statistically significant. We conclude that acute brachymetatarsia correction can obtain correction similar to the gradual technique with fewer postoperative complications and less osseous consolidation time.

The Use of Fluorescence In situ Hybridisation in the Diagnosis of Hidden Mosaicism in Egyptian Patients with Turner Syndrome

Background

Turner syndrome (TS) is the most common chromosomal abnormality in females. The diagnosis of TS is based on karyotyping of 30 blood lymphocytes. This technique does not rule out tissue mosaicism or low-grade mosaicism in the blood. Because of the associated risk of gonadoblastoma, mosaicism is especially important in case this involves a Y chromosome.

Aims

This study was set to determine the value of additional genetic studies such as fluorescent in situ hybridisation and the inclusion of buccal cells in search for mosaicism in TS patients.

Settings and Design

This cross-sectional, descriptive study was performed in Human Genetics Department, Medical Research Institute, Alexandria University.

Materials and Methods

Fluorescence in situ hybridisation technique was applied to lymphocyte cultures as well as buccal smears using centromeric probes for X and Y chromosomes. Genotype phenotype correlation was also evaluated.

Statistical Analysis Used

Descriptive study where categorical variables were described using number and percentage and continuous variables were described using mean and standard deviation.

Results

Fluorescence in situ hybridisation technique study detected hidden mosaicism in 60% of studied patients; 20% of patients had a cell line containing Y material, while 40% had variable degrees of X, XX mosaicism, and in the remaining 40% no second cell line was detected. Fluorescence in situ hybridisation study helped identify the origin of the marker to be Y in all patients. The introduction of an additional cell line helped in identifying mosaicism in patients with monosomy X. Virilisation signs were only observed among TS patients with Y cell line mosaicism. The clinical manifestations were more severe in patients with monosomy X than other mosaic cases.

Conclusions

Molecular cytogenetic investigation for all suspected cases of TS should be considered for appropriate treatment plan and genetic counselling.

Percutaneous Partial Bone Excision in the Management of Diabetic Toe Osteomyelitis

BACKGROUND

Diabetic foot osteomyelitis affecting the toes is associated with several complications including amputation. Management is variable and include medical therapy alone or coupled with surgery. Removal of infected tissues is a common therapeutic option. However, limited source data are available. This study determines the outcome and complications of percutaneous partial bone excision (PPBE) of infected bone among diabetic patients with toe osteomyelitis.

METHODS

This is an uncontrolled experimental prospective study in diabetic patients who underwent PPBE of infected pieces of bone for toe osteomyelitis in the outpatient setting at a single foot clinic. All participants were followed up until the occurrence of wound healing or amputation.

RESULTS

Forty-seven patients (mean ± SD age was 62.8 ± 11.6 years) participated. Forty-four patients (93.6%) had complete healing and 3 (6.4%) required toe amputation. The mean (±SD) wound healing time was 11 (±4.6) (range, 7-22) weeks. Diabetes mellitus type 1 and younger age were significantly associated with increased risk for amputation.

CONCLUSION

PPBE of infected toes in diabetic patients can be performed successfully and safely in the outpatient clinic. It can also improve healing and avoids inpatient stay.

LEVEL OF EVIDENCE

Level II, prospective cohort study.

A Rare Observation of Brachymetacarpia and Brachymetatarsia in a Patient with Primary Idiopathic Hypoparathyroidism

Brachymetacarpia and brachymetatarsia are unique clinical entities associated with numerous rare conditions. Primary hypoparathyroidism is distinct from pseudohypoparathyroidism and pseudopseudohypoparathyroidism by lacking skeletal changes such as short metacarpals or metatarsals. Here, we present a case of a 64-year-old patient with brachymetacarpia and brachymetatarsia presented with hypocalcemic symptoms and signs, bilateral cataracts, and basal ganglia calcifications, subsequently diagnosed with idiopathic primary hypoparathyroidism. This is a rare case describing such an infrequent observation of brachymetacarpia and brachymetatarsia in primary idiopathic hypoparathyroidism.

The Prevalence of Bunions in the Setting of Brachymetatarsia

Brachymetatarsia is caused by premature closure of the physis and is characterized by a short metatarsal. Additional foot conditions may exist in patients presenting with brachymetatarsia, such as hallux valgus (HV). A retrospective study was performed to evaluate the prevalence of HV and brachymetatarsia in the ipsilateral foot. Ninety-seven feet with congenital brachymetatarsia were reviewed in a multi-study cohort of 66 patients who underwent surgical correction between January 2005 and August 2020 at a single institution. The group was comprised of 61 females and 5 males, with a mean age of 27 years. HV deformities were verified with standardized anteroposterior radiographs. HV was present in 29 of 97 feet for a prevalence of 30% in the feet with brachymetatarsia. Our results demonstrate a 30% prevalence of HV associated with brachymetatarsia. This information is helpful for foot and ankle surgeons managing brachymetatarsia to determine appropriate conservative or surgical management of this condition.

Callus distraction for brachymetatarsia - A comparison between an internal device and the external fixator

BACKGROUND

Symptomatic patients with severe brachymetatarsia are commonly treated with callus distraction using external mini-fixator (EF) or internal device (ID). This study points out advantages and limitations of both methods comparing clinical and radiographical parameters.

METHODS

Retrospective analysis of 21 metatarsal bones in twelve patients. Twelve metatarsals were treated with ID (Genos Mini), nine with EF (MiniRail).

RESULTS

Mean lengthening distance was 17.3 mm using EF and 11.7 mm using ID (p = 0.016). Adverse results were observed in 89% of metatarsals treated with EF and in 33% treated with ID (p = 0.011). Postoperative surgical intervention was required in 33% using EF compared to 0% using ID (p = 0.031). Mean total German Foot Function Index (FFI-T) improved from 49 to 33 using EF and from 47 to 22 using ID (p < 0.001).

CONCLUSION

CD is a reliable surgical treatment for BMT. Surgeons should be aware of implant-related advantages and complications when counseling patients about treatment options.

The Surgical Treatment of Brachymetatarsia

This article describes the 3 main surgical options for correction of congenital brachymetatarsia in childhood. The one-stage lengthening by lengthening osteotomy and lengthening with graft interposition are suitable for defects less than 10 mm. For the greater defects from 10 mm to more than 20 mm, gradual lengthening by callus distraction with an external or internal fixator is appropriate. Over the last years, callus distraction with an internal minifixator became commonly established because of the significantly improved aftercare with early full weight-bearing and high postoperative comfort for the child. All 3 surgical procedures are presented with comprehensive image material.

Aetiology, diagnosis, and treatment of brachymetatarsia: a narrative review

Brachymetatarsia (BM), or hypoplastic metatarsal, is an abnormal shortening of one or more metatarsal bones with a female-to-male ratio of 10.53:1. Different causes are described in the literature, such as congenital, acquired, or iatrogenic, associated with different conditions and syndromes. Its presence may develop deformity and pain; however, often feet are pain free and the major worries of patients are cosmetics. Non-operative treatments aim to improve the comfort of metatarsal heads and the possible dorsal conflict through comfortable shoes or the use of specific orthotics. The surgical treatment is anything but straightforward, with "one-stage" or "two stage" techniques, the latter better called "by gradual distraction". One-stage procedures are more rapid techniques but have limited ability to restore the desired length due to neurovascular compromise caused by acute lengthening. Insufficient correction is also possible. On the contrary, by gradual distraction procedures allow gradual distraction lengthening of more than 1.5 cm, but require the use of an external fixator, with a higher risk of complications in more than about 50% of surgeries. The adjacent metatarsal shortening should be considered in combination with other techniques, to diminish the excessive lengthening. In each case, surgeries should be always decided on each patient's concerns, deformities, and clinical needs.

Three cases of brachydactyly type E from two commingled tombs at the Late Intermediate period - Late Horizon site of Marcajirca, Ancash, Peru

OBJECTIVE

Here we present the first known examples of brachydactyly from an Andean archaeological context by describing the affected bones, presenting a differential diagnosis, and discussing the cultural implications of there being shortened metapodials in multiple tombs.

MATERIALS

3232 well-preserved tubular bones representing an MNI of 250 human adults.

METHODS

Each bone was visually inspected. Measurements were taken with an osteometric board, sliding calipers, and a flexible tape measure.

RESULTS

Of 1210 metapodials excavated from eight burial contexts, ten were atypically short.

CONCLUSIONS

The ten shortened elements represent an MNI of three individuals with brachydactyly from two tombs. The presence of at least two individuals with brachydactyly in one tomb adds support to a previous suggestion that tombs were used for familial interment. It is plausible that the third individual from a different tomb was related to the other two, and the different burial contexts may reflect postmarital practices.

SIGNIFICANCE

These cases offer insight into tomb use and underscore the importance of identifying rare developmental anomalies in the archaeological record as their presence may indicate genetic relationships within or among archaeological cemeteries.

LIMITATIONS

With commingled contexts and incomplete recovery of skeletal remains, individualizing the brachydactylous elements was not possible. There is also a lack of comparative data from other Andean sites.

SUGGESTIONS FOR FURTHER RESEARCH

Identify more Andean cases of brachydactyly to learn if the relatively frequent involvement of the first digit is more common among Andean skeletal samples than North American, or if it is unique to Marcajirca.

Brachymetacarpia and brachymetatarsia: do we need to operate?

Brachymetacarpia and brachymetatarsia are rare congenital presentations denoted by shortening of metacarpals and metatarsals respectively, in which the deformity usually presents around childhood/early adolescence.

The aetiology is usually congenital besides several other syndromic or endocrinologic associations.

Cosmetic issues such as absence of a normal-looking knuckle while making a fist or disruption of finger-tip curvature besides functional issues are the main indications for surgical intervention in brachymetacarpia.

In the foot, apart from cosmetic issues, pain due to transfer metatarsalgia as well as callosities along with toe deformities which lead to difficulty of using footwear are the main indications for intervention.

Lengthening of the affected bone, either acute with grafting or gradual, is the mainstay of treatment. Gradual lengthening can be either single-stage as in callotasis, or two-stage where the primary procedure is followed by bone grafting after the length has been achieved.

Adolescence, specifically between 12 and 15 years, is the preferred period for surgical intervention in these cases.

Cite this article: EFORT Open Rev 2021;6:15-23. DOI: 10.1302/2058-5241.6.200087

Brachymetacarpia and Brachymetatarsia in Patients with Multiple Hereditary Exostosis

Background

Multiple hereditary exostosis is a common autosomal dominant inherited musculoskeletal disorder that manifests with multiple osteochondromas. The clinical manifestations and pathological characteristics of osteochondromas found in the long bone and genetic alterations related to multiple hereditary exostosis have been widely reported. In this study, we investigated the characteristics of brachymetacarpia and brachymetatarsia associated with multiple hereditary exostosis.

Methods

Of the 133 patients with a diagnosis of multiple hereditary exostosis who were recruited from 2005 to 2018, 101 patients who underwent plain radiography after 10 years of age were included. There were 55 male (54.5%) and 46 female (45.5%) patients. Brachymetacarpia or brachymetatarsia was diagnosed when disruption of the Lièvre parabola connecting the metacarpal or metatarsal heads was observed on plain radiographs. Three orthopedic surgeons individually reviewed hand and foot plain radiographs.

Results

Of the 101 patients, 41 patients (40.6%) had more than 1 brachymetacarpia (88 cases) or brachymetatarsia (81 cases). Among 41 cases, 22 (53.7%) were male and 19 (46.3%) were female. The mean age at the time of radiographic evaluation of the hands and feet was 14.6 years (range, 10–63 years). Shortening was most commonly found in the 3rd and 4th metacarpal or metatarsal bones.

Conclusions

We found a relatively high incidence of brachymetacarpia and brachymetatarsia in our patients. Physicians should suspect the presence of brachymetacarpia and brachymetatarsia when treating patients with multiple hereditary exostosis.

Callus distraction with external fixator for the treatment of congenital brachymetatarsia of the fourth ray

BACKGROUND

Brachymetatarsia is a rare abnormality of the foot which occurs most frequently in the first and fourth metatarsals. The aim of this study was to evaluate the efficacy of gradual metatarsal lengthening by external fixator for treatment of brachymetatarsia of the fourth ray. The hypothesis was that with external fixation it would be possible to achieve the desired length of the metatarsal with a low rate of complications. Secondarily, in cases requiring a greater amount of correction, it was hypothesized that an opportune rate of bone consolidation would be achievable using a traditional oscillating saw without predrilling or use of a cold osteotome.

METHODS

Between 2013 and 2016, 12 eligible patients and 13 feet underwent gradual metatarsal lengthening by an external fixator (MiniRail System M103, Orthofix) due to brachymetatarsia of the fourth ray. Mean age at surgery was 24.5±5.3 years (range 19-36), with mean follow-up of 22.3±8.3 months. Clinical evaluation was performed with the AOFAS lesser metatarsophalangeal-interphalangeal (MTP-IP) score. Radiographic assessment was performed on follow-up using non-weightbearing dorsoplantar foot radiographs.

RESULTS

The mean AOFAS lesser MTP-IP score improved from a preoperative score of 76.6±7.1 points (range 62-85 points) to a postoperative score of 90.3±3.0 points (range 86-95 points). The average amount of lengthening was 16.8±3.9mm (range 8-22mm). Mean shortening, final lengthening, Healing Index, period of treatment, and complications are also reported. The operative technique is described.

CONCLUSIONS

Gradual metatarsal lengthening with external fixator is an effective treatment for brachymetatarsia and can restore forefoot anatomy with good clinical outcomes, a low rate of morbidity and complications in selected cases. Particular attention should be given when treating patients with shortening >20mm.

Brachymetatarsia: One-stage Versus Two-Stage Procedures

Brachymetatarsia is a rare deformity with controversial clinical presentation. Multiple acute and gradual lengthening surgical techniques have been described for correction of this type of foot deformity. All techniques try to create a better appearance, facilitate shoeing, or solve possible transfer metatarsalgia. Either acute lengthening (1-stage procedure) or gradual lengthening (2 stages) is selected based on the patient's deformities, concerns, and clinical needs.

A rare case of isolated congenital unilateral brachymetatarsia presenting in a young adult male

Congenital brachymetatarsia is a rare skeletal anomaly which is characterized by the abnormal length reduction of one or more metatarsal bones. It occurs as the result of the early closure of the growth plate. While the majority of the reported cases are idiopathic, it can also be seen in association with various genetic conditions or syndromes. Brachymetatarsia most commonly involves the fourth metatarsal followed by the first metatarsal. This rare disorder is mostly bilateral and reported almost exclusively in females. Herein, we present a rare case of congenital unilateral brachymetatarsia which was incidentally detected in a young adult male.

One-Stage Metatarsal Interposition Lengthening With an Autologous Fibula Graft for Treatment of Brachymetatarsia

Objective: Brachymetatarsia is defined as the pathological shortening of a metatarsal bone, which can cause cosmetic problems and pain in the forefoot. The main surgical treatment options are: extension osteotomy, interposition of a bone graft, and callus distraction. Usually, a bone graft from the iliac crest is used for the interposition osteotomy. The operative technique of graft extraction from the fibula has not been described in the literature yet. Methods: Eight feet with brachymetatarsia in 5 patients were evaluated retrospectively. The minimum follow-up period was 2 years. Via a dorsal V/Y skin incision, a central osteotomy on the metatarsal bone was done. A graft was obtained from the anterior fibula. The graft was inserted and fixed by a locking plate. Additional soft tissue procedures were done. Results: We had bony consolidation in all cases. The mean extension was 9.01 mm (5.49 to 12.54 mm). This corresponded to a mean 20.3% extension of the entire metatarsal. High patient satisfaction as well as high satisfaction regarding the cosmetic results were achieved. There were no postoperative complications. The range of motion of the metatarsal-phalangeal joint IV was 20% less preoperative in terms of plantar flexion. Standing up on tiptoes was possible in all patients postoperatively. One patient reported mild symptoms after sports activities. Conclusions: Because of its anatomy the graft adapts to the metatarsal IV bone. As our study showed, harvesting from the distal fibula causes no functional restriction. In terms of wound and bone healing as well as pain symptoms, this method should be considered as an alternative to the standard iliac graft.

Mini-Invasive Treatment for Brachymetatarsia of the Fourth Ray in Females: Percutaneous Osteotomy With Mini-Burr and External Fixation-A Case Series

Brachymetatarsia is a rare disease defined by metatarsal shortening and characterized by aesthetic dissatisfaction with or without pain. The aim of our study was to evaluate the outcomes of fourth ray brachymetatarsia treated with percutaneous osteotomy using a mini-burr and gradual lengthening with external fixation. A total of 7 females were recruited for the study; 6 (85.71%) of whom had a bilateral deformity, for a total of 13 feet affected by fourth ray brachymetatarsia. Percutaneous diaphysis osteotomy with a mini-burr followed by metatarsal elongation was performed. Metatarsal lengthening was measured as the difference between the preoperative and postoperative length at external fixator removal. The American Orthopaedic Foot and Ankle Society lesser toe metatarsophalangeal-interphalangeal score, patient satisfaction, restoration of Leliévre parabola, and treatment time were evaluated. Numerical data are reported as the mean ± standard deviation and 95% confidence intervals. The Mann-Whitney U test was used to compare the changes in the AOFAS score with a level of significance of p < .05. The mean metatarsal lengthening was 17.46 ± 4.89 (95% confidence interval [CI] 14.8 to 20.12) mm and the mean treatment time was 99.23 ± 8.53 (95% CI 94.59 to 103.87) days. The mean American Orthopaedic Foot and Ankle Society lesser toe metatarsophalangeal-interphalangeal score improved significantly from 76.38 ± 2.66 (95% CI 74.77 to 78.03) preoperatively to 86.46 ± 1.45 (95% CI 84.85 to 88.07) postoperatively (p < .01). In 12 of 13 feet (92.31%), the Leliévre parabola was restored, and the patients were satisfied with the clinical outcomes. The results of our study demonstrate that percutaneous osteotomy with the mini-burr and external fixation is an effective treatment for lengthening of fourth ray brachymetatarsia. Furthermore, we found good clinical and functional outcomes, high patient satisfaction, and a similar duration of treatment compared with other gradual lengthening procedures.

A rare combination of brachymetatarsia and congenital hallux varus: case report and review of the literature

Hallux varus is defined as a medial deviation of the phalanx at the first metatarsophalangeal joint and can be congenital or acquired. Brachymetatarsia is defined as shortening of the metatarsal bones. A combination of hallux varus and brachymetatarsia is rare. A 15-year-old girl presented to our outpatient clinic complaining of problems with her feet. A distinctive hallux varus was present bilaterally combined with a brachymetatarsia of the first metatarsals. The patient reported discomfort. She was restricted in her activities and had severe psychological strain owing to the deformity. We decided on surgery. First, a Pennig MiniFixator for callus distraction of the first metatarsal bone was applied. Owing to the increased plantar subluxation of the phalanx during distraction, an extension of the external fixator was administered so that the hallux could be repositioned to a physiologically satisfying position. After sufficient callus formation, the hardware was removed 14 weeks after surgery. Thereafter, the phalanx moved back to the subluxed position. Finally, an arthrodesis of the first metatarsophalangeal joint was performed with a locking plate. Surgery should not be made only for cosmesis and associated psychological aspects; but, discomfort should be the deciding factor. The postoperative clinical and cosmetic results in our case were good, and the patient was quite satisfied. There was no longer any preoperative discomfort and pain.

Treatment of Complications after Distraction Osteogenesis for Brachymetatarsia of the Fourth Metatarsal

Congenital brachymetatarsia most commonly involves the fourth ray and may be combined with metacarpal shortening. Numerous reports have demonstrated the usefulness of gradual lengthening of the metatarsals. However, very few studies have investigated methods of recovering the lost regenerative bone. The patient was a 16-year-old girl with bilateral brachymetatarsia of the fourth metatarsal. After a long consolidation period after gradual lengthening of the fourth metatarsal by 20 mm, the patient had an hourglass-shaped regenerated bone. Therefore, we grafted a bioabsorbable hydroxyapatite and collagen composite. Six months after the surgery, well-regenerated bone could be recognized on radiographic evaluation and was resistant to refracture. Callus distraction is a method that aims to avoid donor site morbidity. The strength of artificial bone is often a problem. Bioabsorbable hydroxyapatite and collagen composite compensates for the lack of regenerated bone and distraction gap and prevents refracture, thus preventing complications after metatarsal distraction.

[Treatment options for brachymetatarsia]

Brachymetatarsia can be congenital, idiopathic or secondary and describes an abnormal shortening of a metatarsal bone. The indications for treatment are not only due to cosmesis. The shortening of a ray changes the biomechanics of the foot and can lead to metatarsalgia. A frequent clinical feature is dorsal dislocation of a toe causing painful shoe conflict and disturbed proprioception. There are three main options for operative correction: lengthening osteotomy, interposition of a tricortical bone and gradual lengthening by callus distraction. While one stage lengthening procedures such as osteotomy and interposition are more appropriate for correction of moderate length deficiencies, the callus distraction method is more suitable for larger elongation. Common to all procedures is a long-term treatment with a high risk of different complications whereby patient compliance can be problematical.

Comparison of the outcomes of distraction osteogenesis for first and fourth brachymetatarsia

BACKGROUND

Brachymetatarsia is the presence of an abnormally short metatarsal, and distraction osteogenesis has been used for its treatment. The purpose of the present study was to compare the outcomes of patients who underwent distraction osteogenesis for the treatment of first and/or fourth brachymetatarsia.

METHODS

The data from forty-eight patients (sixty-four feet, seventy-four metatarsals) who underwent distraction osteogenesis for the treatment of brachymetatarsia were reviewed. The indications for surgery included a metatarsal that was at least 10 mm shorter than the adjacent metatarsal and that had an unacceptable cosmetic appearance. The study group comprised thirty-two first brachymetatarsia in nineteen patients (Group A) and forty-two fourth brachymetatarsia in twenty-nine patients (Group B). The average age was twenty years in Group A and eighteen years in Group B. The average duration of follow-up was 58.1 months in Group A and 56.1 in Group B. Metatarsal length, lengthening gain, healing time and index, and the American Orthopaedic Foot and Ankle Society hallux metatarsophalangeal-interphalangeal and lesser metatarsophalangeal-interphalangeal scores were evaluated.

RESULTS

All patients were satisfied with the final length of the metatarsal and all had achieved bone union at the time of the last follow-up. The mean lengthening gain was 17.2 mm (42.9%) in Group A and 16.3 mm (37.3%) in Group B. The mean healing index was 71.0 days/cm in Group A and 67.3 days/cm in Group B. The mean American Orthopaedic Foot and Ankle Society score was 91.2 points in Group A and 92.8 points in Group B at the last follow-up (twenty-two excellent, nine good, and one fair results in Group A, and twenty-nine excellent, eleven good, and two fair results in Group B). The most common complication was metatarsophalangeal joint stiffness, which occurred in thirteen rays in Group A and in twelve rays in Group B; malalignment of the lengthened metatarsal was observed six times in each group. No significant intergroup differences in the outcomes were found.

CONCLUSIONS

Distraction osteogenesis for first and/or fourth brachymetatarsia provided successful lengthening of a metatarsal with eventual osseous union and was associated with similar outcomes in terms of healing index, function score, and the prevalence of complications between the two groups, although frequent complications were encountered and no improvement in foot function was found.

Problems, obstacles, and complications of metatarsal lengthening for the treatment of brachymetatarsia

Metatarsal lengthening by distraction osteogenesis is a challenging procedure that is associated with various adverse results. This article presents and classifies adverse results arising from metatarsal lengthening. Our premise of classification is that not all adverse results that occur secondary to distraction osteogenesis of the metatarsal are true complications that affect the final outcome, but rather are problems and obstacles that present hurdles to completion of treatment. Our classification differentiates among problems, obstacles, and complications during metatarsal lengthening with external fixation. The cause of each adverse result is also discussed and clinical and surgical pearls to avoid these problems, obstacles, and complications are presented.

One-stage metatarsal lengthening by allograft interposition: a novel approach for congenital brachymetatarsia

BACKGROUND

Congenital brachymetatarsia, a shortened metatarsal bone, can be corrected surgically by callus distraction or one-stage lengthening using bone graft.

QUESTIONS/PURPOSES

We asked whether one-stage metatarsal lengthening using metatarsal homologous bone graft could improve forefoot function, lead to metatarsal healing, restore metatarsal parabola, and improve cosmetic appearance.

PATIENTS AND METHODS

We retrospectively reviewed 29 patients (41 feet) in whom we lengthened 50 metatarsals. Surgery consisted of a transverse proximal osteotomy of the metatarsal shaft and interposition of a metatarsal homologous bone graft (average, 13 mm long) fixed with an intramedullary Kirschner wire. Minimum followup was 3 years (mean, 5 years; range, 3-11 years).

RESULTS

Bone union was achieved in all cases. The mean preoperative American Orthopaedic Foot and Ankle Society score was 37 points (range, 28-53 points) and the mean postoperative score was 88 points (range, 74-96 points), with an average improvement of 51 points. Radiographically, the mean gain in length was 13 mm (range, 10-15 mm), and the mean percentage increase was 23%.

CONCLUSIONS

One-stage metatarsal lengthening using interposition of metatarsal homologous bone graft to correct congenital brachymetatarsia has low morbidity for the patient, limited complications, short recovery times, and restores forefoot anatomy.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Lengthening of fourth brachymetatarsia by three different surgical techniques

We carried out a retrospective study to assess the clinical results of lengthening the fourth metatarsal in brachymetatarsia in 153 feet of 106 patients (100 female, six males) using three different surgical techniques. In one group lengthening was performed by one-stage intercalary bone grafting secured by an intramedullary Kirschner-wire (45 feet, 35 patients). In the second group lengthening was obtained gradually using a mini-external fixator after performing an osteotomy with a saw (59 feet, 39 patients) and in the third group lengthening was achieved in a gradual manner using a mini-external fixator after undertaking an osteotomy using osteotome through pre-drilled holes (49 feet, 32 patients). The mean age of the patients was 26.3 years (13 to 48). Pre-operatively, the fourth ray of the bone-graft group was longer than that of other two groups (p < 0.000). The clinical outcome was compared in the three groups. The mean follow-up was 22 months (7 to 55).

At final follow-up, the mean lengthening in the bone-graft group was 13.9 mm (3.5 to 23.0, 27.1%) which was less than that obtained in the saw group with a mean of 17.8 mm (7.0 to 33.0, 29.9%) and in the pre-drilled osteotome group with a mean of 16.8 mm (6.5 to 28.0, 29.4%, p = 0.001). However, the mean time required for retention of the fixation in the bone-graft group was the shortest of the three groups. Patients were dissatisfied with the result for five feet (11.1%) in the bone-graft group, eight (13.6%) in the saw group and none in the pre-drilled osteotomy group (p < 0.000). The saw group included eight feet with failure of bone formation after surgery. Additional operations were performed in 20 feet because of stiffness (n = 7, all groups), failure of bone formation (n = 4, saw group), skin maceration (n = 4, bone-graft group), malunion (n = 4, bone-graft and saw groups) and breakage of the external fixator (n = 1, saw group).

We conclude that the gradual lengthening by distraction osteogenesis after osteotomy using an osteotome produces the most reliable results for the treatment of fourth brachymetatarsia.