Metatarsal lengthening by callus distraction for brachymetatarsia

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

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.

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.

Brachymetatarsia with accessory navicular in right foot: A rare coincidental finding

A 33 years old female patient presented with posttraumatic pain in the right foot for which radiographs of the right foot was advised. No fracture was detected on radiographs and patient was managed conservatively on medications and posterior splint immobilization. We found coincidentally a short fourth metatarsal and an accessory navicular bone in the right foot radiographs. After 3 weeks of immobilization, she underwent mobilization of the right foot, weight bearing and intensive physio- therapy for 6 weeks. After two months of injury she was still complaining of pain on the plantar aspect of right foot which was diagnosed as metatarsalgia and operated on by excision of the neuroma present in the 3rd web space of the right foot. After surgery she was completely relieved of pain and could do activities well related to the right foot.

Gradual Metatarsal Lengthening by External Fixation: A New Classification of Complications and a Stable Technique to Minimize Severe Complications

BACKGROUND

The surgical management of brachymetatarsia remains controversial, and choice is based on potential complications. We report a classification of complications based on severity, and we hypothesized that use of a semicircular external fixator would minimize severe complications in lateral metatarsal lengthening.

METHODS

We retrospectively reviewed 30 patients (10 to 46 years old) with single or multiple brachymetatarsia and performed 54 metatarsal lengthenings with a mean follow-up of 7 months.

RESULTS

The mean gain in length was 15 mm (33.7%), and the mean healing index was 67 d/cm. No further procedure was performed. No dislocations or subluxations were reported, but 26 complications (48.1%) occurred, classified as 1 severe (1.8% of the metatarsals), 5 intermediate (9.3%), and 20 benign (37%): 4 incomplete osteotomies, 8 adjacent metatarsal osteotomies, 2 involuntary adjacent metatarsal fixations due to the lack of fluoroscopy use, 6 early consolidations, 2 metatarsal fractures, 2 skin complications, 1 superficial infection, and 1 metatarsophalangeal clinodactyly.

CONCLUSION

A classification of complications based on severity was developed. Gradual lengthening of the lateral metatarsals by semicircular external fixation reduced the risk of severe complications because of stability without donor site morbidity. Thin wires were an advantage in the pediatric population.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Congenital lesser toe abnormalities

The treatment of congenital abnormalities of the lesser toes should be individualized to the pathology present. Goals of treatment include pain relief, proper alignment of the toes, and comfort with wearing shoes. Meticulous surgical technique can minimize complications and optimize clinical outcomes for these patients.

A modified surgical technique for lengthening of a metatarsal using an external fixator

Brachymetatarsia is a congenital or developmental condition that results in a short metatarsal. Problems that arise from this condition can include pain, difficulty with shoe wear, and cosmetic concerns. Multiple techniques have been described that successfully correct the deformity, including both acute and gradual distraction. We describe a modification of the technique of gradual lengthening by way of distraction osteogenesis in which an axial transarticular K-wire is incorporated into a monolateral frame, thereby increasing the stability of the construct and potentially minimizing complications.

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.

Lengthening of short bones by distraction osteogenesis--results and complications

We performed bone lengthening surgery on 12 metacarpals and 14 metatarsals of 15 patients. The mean age for metacarpal and metatarsal lengthening was 14.5 (10-21) and 17.5 (10-25) years, respectively. We used a unilateral or a circular external fixator. The mean healing index of the metacarpals and metatarsals was 1.6 (1.1-2.3) and 1.6 (1.0-2.0) months/cm, respectively. The mean increase in metacarpal and metatarsal length was 17.6 (13-26) and 24.3 (20-30) mm, respectively. The functional scores of the metatarso-phalangial (MTP) joint of lengthened metatarsals for the lesser toe were excellent in 12 and good in two cases based on the American Orthopaedic Foot and Ankle Society (AOFAS) scoring system. Complications were seen in six of the metatarsal lengthening cases including four angulations, one subluxation and one non-union. We conclude that the periosteum must be protected with percutaneous osteotomy and lengthening should be performed at a rate of 0.25 mm twice a day and should not exceed 40% of the original bone length (or >20 mm).