Percutaneous distraction osteogenesis for treatment of brachymetatarsia

Treatment of Fourth Metatarsal Brachymetatarsia Using Distraction Osteogenesis with External Fixator: Surgical Techniques, Outcomes and Complications

OBJECTIVE

Surgical technique in distraction osteogenesis for the treatment of brachymetatarsia can influence the final prognosis. However, there are currently no standardized guidelines for surgical procedures and complication management. The aim of this study is to investigate the effect of bone lengthening with external fixation by minimally invasive osteotomy based on Ilizarov technique in the treatment of congenital brachymetatarsia.

METHODS

A retrospective study was conducted on patients with congenital brachymetatarsia treated by metatarsal lengthening, from June 2017 to December 2020. There were 11 patients with 17 shorted fourth metatarsals, including 10 females and 1 male, with age of 24.6 ± 4.5 years (16-31 years). Six patients were bilaterally involved. Orthofix external fixator mini track was installed through dorsal approach and the fourth MTP joints were temporarily fixed by Kirschner wire. Bone lengthening was performed after a minimally invasive osteotomy at the proximal metatarsals. American Orthopedic Foot and Ankle Society (AOFAS) lesser metatarsophalangeal-interphalangeal (MTP-IP) scores, metatarsal length, complications were recorded. Statistical comparison was performed using the paired t-student test for pre- and postoperative AOFAS MTP-IP scores.

RESULTS

Patients were followed up for 55 ± 10.8 months. The mean length of the fourth metatarsal bone was 49.9 ± 2.9 mm preoperatively. The mean metatarsal shortage was 18.8 ± 3.1 mm. The mean lengthening achieved was 19.8 ± 3.3 mm, with a lengthening ratio of 39.7% ± 6.6%. The lengthened callus ossified completely at 3-4 months after operation. All patients were satisfied with the results of lengthening. The AOFAS scores were improved significantly from 83.7 ± 4.2 preoperatively to 93.2 ± 2.7 postoperatively (t = -10.27, p < 0.001). One patient with traumatic metatarsophalangeal joint subluxation was treated by joint reduction and Kirschner wire fixation. One patient had metatarsophalangeal joint release and Kirschner wire fixation due to flexion contracture. Pin tract infections were controlled by wound care and antibiotics in 6 patients. All patients had no nonunion, necrosis of toes, and sensory disturbance of toes.

CONCLUSION

Metatarsal lengthening by minimally invasive osteotomy with external fixator had satisfactory results in the treatment of congenital brachymetatarsia.

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.

Brachymetatarsia: A Classification for Surgical Treatment

Brachymetatarsia is a congenital osseous and soft tissue deformity of a ray(s) of the foot. Because there is no particular consensus of methodology of lengthening for brachymetatarsia, the authors introduce a comprehensive anatomic classification and a surgical guide to treatment of each classification type. This classification combines the number of the metatarsal(s) affected and the letter(s) indicating the type of brachymetatarsia deformity (A = axial deficiency of the metatarsal, B = bowing of the metatarsal, C = congruency of metatarsal phalangeal joint). This study reviewed of 300 brachymetatarsals in 166 patients. Fifty of the 166 (30%) patients had bilateral brachymetatarsia. Of the 300 metatarsals with brachymetatarsia, 64 (21%) were first metatarsals, 22 (7%) were second metatarsals, 28 (9%) were third metatarsals, 12 (4%) were fifth metatarsals, and 174 (58%) were fourth metatarsals. Classification types that were found was a total of 165 (55%) type A, a total of 6 (2%) type B, a total of 72 (24%) type AB, a total of 39 (13%) type AC, and a total of 18 (6%) type ABC. A total of 16 (10%) male and 150 (90%) female patients were evaluated. The mean preoperative amount of shortening of the metatarsal was 15 mm (range, 4-20 mm), as determined by the preoperative metatarsal parabola deficiency, equating to 30% of the preoperative metatarsal length. Brachymetatarsia is a complex congenital deformity which until now has not been critically analyzed. This study outlines a comprehensive brachymetatarsia classification system which provides an accurate diagnosis of the deformity and offers a surgical treatment algorithm.

The Role of the Shortened Proximal Phalanx in the Setting of Brachymetatarsia

Brachymetatarsia is a condition in which a metatarsal bone does not grow out to full length. This is caused by premature physeal closure. The proximal phalanx associated with the shortened metatarsal helps achieve the natural parabola of the foot. A hypoplastic proximal phalanx is a common finding in patients with brachymetatarsia. The goal of this study was to determine the length of the proximal phalanx in the setting of brachymetatarsia, and how much the shortening is attributed to the clinically smaller toe. We performed a retrospective study to evaluate the length of the proximal phalanx in the shortened ray. After the metatarsal was brought out to the desired length of correction, the proximal phalanx was measured on radiographs. Ninety-seven feet with congenital brachymetatarsia were reviewed in a cohort of 66 patients who underwent surgical correction between January 2005 and February 2020 at a single institution. The group was comprised of 61 females and 5 males, with a mean age of 27.5 years. The average length of the proximal phalanx associated with the affected metatarsal was noted to be 18.9 ± 3.83 mm for males and 15.6 ± 4.02 mm for females. Our results indicate the shortened proximal phalanx is 5 mm shorter when compared to normal population and is a contributing factor to the shortened clinical appearance of the digit in brachymetatarsia. Treating surgeons should be aware of this to better educate patients on the influence of the digit on the overall shortening seen in cases of brachymetatarsia.

Metatarsal Gradual Lengthening for Brachymetatarsia Using a Mini-rail External Fixator System

Aim

To describe the surgical technique for gradual lengthening of the metatarsal using the Orthofix MiniRail System (Orthofix Medical Inc., Lewisville, TX, USA).

Background

Brachymetatarsia refers to the shortening of the metatarsal bone. When indicated, metatarsal lengthening is performed to treat this deformity.

Technique

A dorsal approach to the short metatarsal is performed, protecting the neurovascular structures and the extensor tendons. The most proximal wire or screw is inserted first, followed by the most distal wire or screw. The distal wire or screw should not be inserted in the metatarsal head. The middle wires or screws are inserted thereafter. All wires or screws should be placed perpendicular to the anatomic axis of the bone. Once the MiniRail lengthener is assembled, a 1.6 mm K-wire is inserted from the tip of the toe into the metatarsal head, blocking the motion of the metatarsophalangeal joint and avoiding joint subluxation during lengthening. The osteotomy is then performed perpendicular to the metatarsal shaft, in between the middle two wires and screws.

Conclusion

The surgical technique for gradual lengthening of the metatarsal using the Orthofix MiniRail System was described in detail with accompanying step-by-step intraoperative clinical and fluoroscopic images.

Clinical significance

This surgical technique of metatarsal lengthening is simple and effective. An understanding of the surgical technique of gradual lengthening of the metatarsal bone is important when treating shorting deformities of more than 1 cm.

How to cite this article

Marwan Y, Abu Dalu K, Bernstein M, et al. Metatarsal Gradual Lengthening for Brachymetatarsia Using a Mini-rail External Fixator System. Strategies Trauma Limb Reconstr 2022;17(3):184-188.

Brachymetatarsia: Surgical Management, Case Report, and Literature Review

Background

Brachymetatarsia is defined by an abnormal shortening of the metatarsal bone. This rare condition is mostly primary and congenital. Consequences of this malformation are both esthetic and functional, due to pain and mechanical problems in the forefoot. Surgical management is an important part of patient care. There are two main options: gradual lengthening by progressive callotosis distraction using an external fixator and one stage lengthening using bone graft and osteotomy of the bone. This review presents two cases using the one stage lengthening surgical management method. We also discuss some reports in the literature with the aim to compare the advantages and disadvantages of the two surgical methods. Literature concerning the surgical management of brachymetatarsia was identified using the PubMed and Google Scholar databases. Patient Presentation. We describe two female patients aged 20 and 26 years who underwent one stage lengthening surgery of the fourth toe with isolated brachymetatarsia using an iliac bone graft and internal fixator plate. The two patients had a lengthening of around 10 mm after postoperative evaluation. No skin complications were noted, but one of the patients reported flexor stiffness after surgery. Concerning the functional and cosmetic aspects, the two patients are satisfied with the management.

Conclusions

In the literature, one stage lengthening seems to be the most favorable option for the care of brachymetatarsia. Studies show a short healing time and fewer complications like infection, stiffness, malalignment, and malunion. Some reviews note the utility of the gradual lengthening of severe brachymetatarsia when a longer lengthening is necessary. There is no definite consensus concerning the management of brachymetatarsia.

Plantar approach for treatment of brachymetatarsia: A novel approach with an aesthetic consideration

In the past, open osteotomy was always performed through a dorsal approach in the surgical treatment of brachymetatarsia, which created scar formation on the dorsal skin, subsequently resulting in dissatisfaction with cosmetic results. In this study, we provided a plantar approach to avoid forming scars on the dorsal side. A retrospective review was conducted in nine patients (13 feet) with brachymetatarsia treated with an open osteotomy and gradual bone lengthening through a plantar approach. Visual analogue scale (VAS) was used to evaluate the satisfaction of foot appearance, and we designed a questionnaire called appearance index (AI) to assess the influence of foot appearance on quality of life after surgery. The complications were also recorded during the follow-up. The patients were followed up for 34.8 ± 23.7 months. All cases were healed with a time of 64.4 ± 7.1 days and a healing index of 44.1 ± 7.8 d/cm. Satisfaction VAS for foot appearance improved from a preoperative score of 1.7 ± 1.3 points to a postoperative score of 9.3 ± 0.5 points. The AI improved from a preoperative score of 9.2 ± 0.8 points to a postoperative score of 0.6 ± 0.7 points. Complications were observed in three feet (23.1%), but none was related to the plantar approach. In conclusion, the plantar approach for metatarsal osteotomy and pins fixation was a safe and efficient technique with a satisfactory cosmetic result for the patients. No complications related to the novel approach, such as neurovascular injury, were reported.

Nonincisional Osteotomy for Gradual Lengthening by Callus Distraction for Congenital Brachymetatarsia

Gradual lengthening by distraction osteogenesis is widely used for congenital brachymetatarsia. The usual presenting complaint is the patient's cosmetic appearance. Osteotomy is an integral element. A nonincisional surgical approach for osteotomy can reduce dorsal longitudinal scarring and help preserve the periosteal blood supply to the bone during surgical dissection. Between June 2003 and January 2019, we performed gradual lengthening by callus distraction with nonincisional osteotomy for congenital brachymetatarsia on 13 digits in 5 patients. All 5 patients were female, and their average age was 18 years old. The lengthened bones involved 3 first metatarsals, 2 third metatarsal, and 8 fourth metatarsal bones. The mean gain in length was 15.2 mm (10-21 mm). The mean duration of distraction was 36.2 days (30-48 days). The mean duration of consolidation was 62.8 days (28-103 days). The lengthened segment consolidated in all cases. One patient had early consolidation and did not wish to undergo further surgery. There were no cases of trouble due to drilling for osteotomy. All patients had a normal gait and were satisfied with the cosmetic results.

Tratamento da braquimetatarsia por distração osteogênica com fixador externo monolateral

Objective  To describe the profile of the patients and the results obtained with the use of an external fixator for metatarsal lengthening in brachymetatarsia.

Methods  A retrospective analysis of the medical records of patients with brachymetatarsia treated between January 2018 and April 2020 was performed. During this period, eight feet of six patients were operated on. Frequencies were estimated according to demographic and surgical aspects.

Results  All patients (100%; n  = 6) were female, with a mean age of 28 years old, ranging from 15 to 48 years old, and were motivated to seek the orthopedic service due to aesthetic deformity. The deformity was bilateral in two patients and unilateral in four patients. The average lengthening time was 22 days ( ± 7.15, 95% confidence interval [CI]: 19.04–26.81). The lengthening speed was 0.5 mm/day, and the average total length of the lengthening was 11.46 mm ( ± 3.57; 95%CI: 9.52–13.40). Half of the patients (50%; n  = 3) had local infection of the pins and were treated with antibiotics, and the others did not report any postsurgical complications. All patients denied pain or calluses after the surgical procedure and reported satisfaction with the results.

Conclusion  All patients were female and sought surgery for brachymetatarsia for aesthetic reasons. Osteogenic distraction at a rate of 0.5 mm/day resulted in successful lengthening of the metatarsal, with a low frequency of complications, good clinical outcomes, and high patient satisfaction.

Hallux Valgus With Second Brachymetatarsia Discovered Accidentally: A Case Report

Hallux valgus deformity is one of the most common foot and ankle diseases, while brachymetatarsia is a rare foot anomaly with pathological shortening of a metatarsal bone. We present a case of hallux valgus deformity possibly due to second brachymetatarsia. As the hallux valgus was associated with dorsal dislocation of the second toe that made it difficult to evaluate the length of the second toe, the patient was unaware of the second metatarsal shortening until the lengths of the toes compared by manual reposition of the second MTP joint. In this case, proximal osteotomy of the first metatarsal on the hallux valgus and single-stage bone lengthening of the second metatarsal with iliac bone grafting on the second brachymetatarsia were performed. One year after the operation, the callosity of the third toe resolved and the clinical scores were improved. In the case of a hallux valgus deformity with second dorsal dislocation of the toes, surgeons should consider that there are rare cases with second metatarsal shortening. When hallux valgus associated with second brachymetatarsia is diagnosed, second metatarsal lengthening should be considered in addition to hallux valgus surgery.

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.

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

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.

Complications of distraction osteogenesis in brachymetatarsia: Comparison between the first and fourth brachymetatarsia

BackgroundRecently, distraction osteogenesis has been widely used to treat brachymetatarsia. However, few papers have compared complications associated with this treatment. The purpose of the present study was to compare the complications between the first and fourth brachymetatarsia treated by distraction osteogenesis. MethodsWe performed distraction osteogenesis to 83 metatarsals in 41 patients between 1999 and 2012. A total of 30 metatarsals received treatment for the first metatarsal (Group A) while 53 metatarsals received treatment with the fourth metatarsal (Group B). ResultsThe complication rate in Group A (40%) was higher than that in Group B (18.9%). Those who had high percentage of lengthening gain were more likely to have complications. A cut-off value for lengthening gain developing complication was 41.3%. ConclusionComplication incidence after distraction osteogenesis was increased when lengthening gain was more than 41.3% for brachymetatarsia. In the 1st metatarsal lengthening, the most common complication was stiffness. In contrast, complications of the 4th metatarsal lengthening were pin-track infection and angular deformity.

Intramedullary Metatarsal Fixation for Treatment of Delayed Regenerate Bone in Lengthening of Brachymetatarsia

Delayed regenerate healing after distraction osteogenesis can be a challenging problem for patients and surgeons alike. In the present study, we retrospectively reviewed the data from a cohort of patients with delayed regenerate healing during gradual lengthening treatment of brachymetatarsia. Additionally, we present a novel technique developed by 1 of us (B.M.L.) for the management of delayed regenerate healing. We hypothesized that application of intramedullary metatarsal fixation would safely and effectively promote healing of poor quality, atrophic regenerate during bone lengthening in brachymetatarsia correction. We formulated a study to retrospectively review the data from a cohort of patients with delayed regenerate healing after gradual lengthening for brachymetatarsia. All patients underwent temporary placement of intramedullary fixation after identification of delayed regenerate healing. Patient-related variables and objective measurements were assessed. We identified 10 patients with 13 metatarsals treated with intramedullary fixation for delayed regenerate healing. All 10 patients were female, with 6 (46.2%) right metatarsals and 7 (53.8%) left metatarsals treated. No complications developed with the use of this technique. All subjects progressed to successful consolidation of the regenerate bone at a mean of 44.5 ± 30.2 days after placement of intramedullary metatarsal fixation. No regenerate fracture or reoperations were noted. In conclusion, intramedullary metatarsal fixation is a safe and effective method for managing delayed regenerate healing encountered during distraction osteogenesis correction of brachymetatarsia.

Results of External Fixation and Metatarsophalangeal Joint Fixation With K-Wire in Brachymetatarsia

BACKGROUND

Brachymetatarsia is a rare foot deformity caused by the premature closure of the metatarsal physis. It may result in functional as well as cosmetic alterations, which may require operative management.

METHODS

A prospective study examining outcomes of 48 cases of brachymetatarsia with gradual bone lengthening at a rate of 1 mm/d using an external fixator and metatarsophalangeal joint fixation was performed. The difference between the length before treatment and after external fixator removal was measured. The patients were assessed at 2, 4, 6, and 8 weeks postoperatively; at the end of the period of distraction; and 1 year after surgery. The total number of patients was 26, and surgery was performed in 48 metatarsals. The mean age was 17.0 ± 4.1 (range, 11-24) years, and all were female.

RESULTS

The fourth metatarsal was the most frequently affected, representing 98% of the cases; the third metatarsal represented the other 2%. The average length gained was 18.6 ± 6.7 mm, and the average length gained as a proportion of the original metatarsal length was 38.2% ± 3.1% (range, 13%-24%). The mean healing time was 71.0 (range, 64-104) days, and the mean healing index (healing time divided by centimeters of length gained [d/cm]) was 38.4 (range, 38.2-50.1) d/cm.

CONCLUSION

Gradual bone lengthening at a rate of 1 mm/d using an external fixator and intramedullary nailing was a safe and efficient method, representing a minimally invasive procedure with a low incidence of complications and satisfactory results for the patient.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Distraction osteogenesis of fourth brachymetatarsia

BACKGROUND

Brachymetatarsia is a rare congenital or developmental condition that results in a short metatarsal. The condition most commonly affects the fourth metatarsal of young and adolescent females. It does not usually produce a functional problem. However, it may produce a significant cosmetic problem especially in young women. The authors present their experience in gradual distraction of the fourth metatarsal to tackle this problem in adults.

METHODS

That was done using a monolateral frame in 11 feet of female patients with an average age of 23 years. Evaluation depended upon the achievement of the target length, angulation, pain, and satisfaction of the patient.

RESULTS

There were eight excellent and three good results after an average follow up of 2.6 years. Aside from nine cases of mild pin-tract infection, complications were few and minor.

CONCLUSIONS

We recommend distraction osteogenesis as the treatment of choice for brachymetatarsia of the fourth toe.

Callus Distraction Versus Single-Stage Lengthening With Bone Graft for Treatment of Brachymetatarsia: A Systematic Review

Brachymetatarsia deformity is a cosmetically displeasing anomaly that can become physically symptomatic. The surgical techniques most commonly used to repair the anomaly include single-stage lengthening with a bone graft, callus distraction, or a combination of bone grafting and callus distraction. A systematic review of the published data was performed to compare the outcomes of these 3 surgical procedures. A total of 61 studies reporting the use of callus distraction or single-stage lengthening, or both, for the treatment of brachymetatarsia were included in the present review. The incidence of major postoperative complications after callus distraction, single-stage lengthening, and the combination procedure was 49 (12.62%), 13 (3.72%), and 3 (33.33%), respectively. The number of minor complications with callus distraction, single-stage lengthening, and the combination procedure was 152 (39.18%), 55 (15.76%), and 1 (11.11%); the mean percentage of the original length achieved was 37.36%, 25.98% and 36.00%; and the mean length achieved was 17.5, 13.2, and 14.0 mm, respectively. The healing index (mo/cm) and healing time was 2.31 and 16.04 weeks, 1.90 and 9.35 weeks, and 3.93 and 14.62 weeks for callus distraction, single-stage lengthening, and the combination procedure, respectively. Our findings indicate that the callus distraction technique is associated with greater length gained but results in greater complication rates and requires almost twice the time to heal. Single-stage lengthening with a bone graft was associated with fewer complications and faster healing times than callus distraction but with lesser gains in length. From the information reported in the studies we reviewed, the prevalence of bilateral brachymetatarsia was 44.52%, and the female/male ratio was 13.7:1. Both of these findings seem to contradict the usual data given (72% for bilateral brachymetatarsia and a female/male ratio of 25:1).

Distraction osteogenesis for complex foot deformities: U-osteotomy with external fixation

BACKGROUND

Certain complex foot deformities can be corrected surgically with a U-osteotomy. This osteotomy is indicated for patients with a uniform deformity of the entire foot relative to the tibia, preexisting stiffness and/or fusion of the subtalar joint, and a pain-free ankle joint. The goal is to create a plantigrade foot through gradual osseous repositioning of the entire foot relative to the tibia by means of external fixation. If needed, foot height can be increased simultaneously.

METHODS

Fifteen complex multiplanar foot deformities in fifteen patients were treated with a U-osteotomy and gradual correction by means of external fixation. Deformities resulted from congenital causes (seven), trauma (three), and developmental causes (five). The mean patient age at the time of surgery was twenty years (range, four to sixty-three years). The mean duration of external fixation was five months (range, three to eleven months). The mean duration of follow-up was five years (range, three to nineteen years). Clinical and radiographic results were assessed.

RESULTS

Osseous union and a plantigrade foot were achieved in all fifteen patients. Seven complications related to the U-osteotomy occurred in four patients, including deep pin-track infection in two, premature osseous consolidation in two, postoperative tarsal tunnel syndrome in two, and peroneal nerve entrapment in one. When comparing the preoperative and final postoperative radiographs, three significant differences were observed: the calcaneotibial angle changed by a mean of 18° valgus (range, 6° to 40° valgus) (p = 0.003), the calcaneus was translated posteriorly by a mean of -8 mm (range, -2 to -20 mm) (p = 0.001), and foot height increased by a mean of 20 mm (range, 3 to 40 mm) (p < 0.001). Fourteen patients were able to walk without supports or assistance; one used only one cane or crutch to walk.

CONCLUSIONS

U-osteotomy with gradual correction by means of external fixation can be used to obtain a plantigrade foot in patients with complex multiplanar deformities of the foot relative to the tibia.

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.