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

Subacute two stage metatarsal lengthening with gradual distraction for brachymetatarsia: A consecutive case series and literature review

BACKGROUND

This study examined the functional and clinical outcomes of subacute two stage metatarsal lengthening with gradual distraction for brachymetatarsia. This technique was developed to overcome the disadvantages of one-stage metatarsal lengthening and gradual distraction.

METHODS

Four feet of three patients with congenital brachymetatarsia underwent subacute two stage metatarsal lengthening with gradual distraction. Pain, function, and alignment were assessed preoperatively and at follow-ups using the American Orthopaedic Foot and Ankle Society (AOFAS) lesser metatarsophalangeal-interphalangeal scale, and any complications were recorded.

RESULTS

The patients were followed up for a mean of 18.1 ± 6.9 (range, 12.6-28.1) months. The mean metatarsal length gain was 15.2 ± 3.2 (range, 12.1-18.5) mm, and the corresponding percent increase was 32.5 % ± 7.0 % (range, 25.7-41.1 %). The mean AOFAS score (0-100) was 97.5 ± 5.0 at the final follow-up. The external fixator index was 10.2 ± 1.5 (range, 8.1-11.6) days/cm. None of the patients experienced metatarsophalangeal stiffness, subluxation or dislocation of the metatarsophalangeal joint, loss of correction, pin tract infection, delayed union, nonunion, or angular deformities.

CONCLUSION

Subacute two stage metatarsal lengthening with gradual distraction is a reliable alternative treatment for brachymetatarsia.

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.

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.

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.

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.

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