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Lesser Metatarsal Osteotomy

Complications 8
Lowell S. Weil and Erin E. Klein

musculature of the foot, and the extrinsic musculature of the


Introduction foot (Fig. 8.1) [16–18].
The metatarsal head has a medial and lateral tubercle upon
Metatarsalgia is defined as pain in the metatarsal region. which the collateral ligaments originate. These structures are
Surgical correction of metatarsalgia can be very difficult. important not only in the stability of the joint but also in
Historically, a high rate of complications has been associated marking an anatomic location for the main blood vessels that
with procedures performed for the treatment of metatarsal- provide arterial flow to the metatarsal head [19] (Fig. 8.2).
gia. A plethora of different types of procedures have been Dissection of the metatarsal head should aim to avoid detach-
described for the surgical management of metatarsalgia. ing the collateral ligaments from the metatarsal head for two
Surgical procedures may be classified by the region of the distinct reasons. First, the collateral ligaments are important
metatarsal bone where they are performed. Procedures can sagittal plane-stabilizing structures for the lesser MTP joint
be done at the head [1–6], the neck [7–10], the shaft, or the [2, 18, 20]. Second, severance of the collateral ligaments may
base of the lesser metatarsal. Resectional procedures [3] of also cause damage to the blood vessels and could, potentially,
the metatarsal head or ray and implant procedures [11] have increase the risk of avascular necrosis and delayed healing to
also been described. When you review what these proce- the metatarsal osteotomy site [19].
dures ultimately accomplish, one will find that the bone can The Weil metatarsal osteotomy was originally described
be either shortened or elevated. Very few procedures as an intra-articular osteotomy that is created as close to par-
described can both of these functions. allel to the weight-bearing surface of the foot as possible.
Early papers on surgical procedures for forefoot problems Surgically, this means that the osteotomy is started within the
report success [1, 7, 12]. However, many subsequent papers cartilage of the metatarsal head [21]. Proper angulation of
discuss complications such as floating toes [13] and transfer the osteotomy (typically 15°) will lead to direct proximal
metatarsalgia [14, 15]. This further illustrates the point that translation with minimal plantar translation of the capital
historically these procedures have been wrought with com- fragment [22]. Improper angulation of the osteotomy will
plications [13]. lead to plantarization of the capital fragment and could
potentially result in continued forefoot pain postoperatively
(Fig. 8.3). It is also important to avoid over-penetration of
 echnique Pearls and Pitfalls: To Avoid
T the plantar cortex of the metatarsal with the saw blade. There
Complications (Central Rays) is a nutrient artery that enters the metatarsal plantarly that
may be at risk if this occurs [19].
The lesser MTP joint is composed of the lesser metatarsal The Weil metatarsal osteotomy was described to shorten the
head, the base of the proximal phalanx, the intracapsular metatarsal 1–3 mm in length in order to avoid plantarization
supporting structures (collateral ligaments), the capsular of the capital fragment [1]. When the osteotomy is performed
supporting structures (including the plantar plate), the intrinsic at the prescribed 15° angle, there will not be plantar transla-
tion if the bone is shortened less than 3 mm [22]. If the meta-
tarsal is to be shortened more than 3 mm in length, a second
parallel osteotomy must be created in order to avoid planta-
L.S. Weil (*) • E.E. Klein
Department of Surgery, Weil Foot and Ankle Institute,
rization of the capital fragment. When a review of the litera-
1455 Golf Road, Des Plaines, IL 60016, USA ture regarding this osteotomy is undertaken, it should be
e-mail: LWJ@weil4feet.com; EEK@weil4feet.com noted that many studies report a shortening of 4–10 mm with

© Springer International Publishing AG 2017 107


M.S. Lee, J.P. Grossman (eds.), Complications in Foot and Ankle Surgery, DOI 10.1007/978-3-319-53686-6_8
108 L.S. Weil and E.E. Klein

Fig. 8.1 (a) A cadaveric (left) and MRI (right) view of a midsection M metatarsal head, PP plantar plate, F flexor tendons, DTML deep
through the second metatarsal at the level of the metatarsal head. P transverse metatarsal ligament, CL collateral ligaments, PF deep
base of the proximal phalanx, M metatarsal head, PP plantar plate, F slips of the plantar fascia
flexor tendon. (b) A frontal image at the level of the metatarsal head.

this osteotomy and a rate of postoperative floating toes as postoperative length of the second or the adjacent metatarsals,
high as 36% [13, 15, 22, 23]. It should be noted that this oste- correcting this at the initial procedure, rather than waiting
otomy was not originally designed to shorten the metatarsal in until problems develop later, may be beneficial [22].
that capacity and that the rate of postoperative floating toes Fixation for the Weil osteotomy should follow basic AO
may be related to the amount of shortening performed. principles. This will assure primary bone healing and
Aggressive shortening can lead to transfer metatarsalgia as decrease the rate of nonunions that occur. As noted above,
the corrected metatarsal could take on a length that overloads maintenance of the blood supply to the metatarsal will also
the adjacent metatarsal(s). If there is a concern about the decrease the incidence of this complication.
8  Lesser Metatarsal Osteotomy Complications 109

Fig. 8.2 (a) A cadaveric specimen of the lesser MTP joint. The proximity of the blood vessels (BV) to the collateral ligament insertion (CLI) can
be seen. (b) The same specimen with the collateral ligaments reflected. (c) The same specimen with the proximal phalanx removed

As with any procedure, postoperative care is important more recent literature [18, 25–28] focuses on the plantar
and can vary from surgeon to surgeon. The postoperative plate as a cause of deformity and pain in the forefoot with
regimen utilized in our institution [21] includes the patient particular emphasis on differentiating plantar plate pain from
being in a bandage and a surgical shoe for 7–10 days. At that neuroma pain [25, 28].
time, the patients are instructed to return to athletic shoes The plantar plate is the main stabilizer of the lesser MTP
with guarded weight bearing and aggressive physical therapy joint, particularly in the direction of plantarflexion [2, 18, 28].
commences. Physical therapy focuses on strengthening of This structure is approximately 2 cm in length and 1 cm in
the intrinsic muscles of the foot and restoring the muscle bal- width and can vary in thickness from 2 to 5 mm [16, 17, 29].
ance to the MTP joint. There is a significant emphasis placed The plantar plate is composed of a combination of type 1 (75%)
on the strength of the plantarflexory muscles and mobility in and type 2 (21%) collagen that is woven together to create a
that direction. Additionally, the patient is instructed to utiliz- fibrocartilaginous structure. The dorsal fibers of the plantar
ing nighttime bracing with the toe strapped in a plantarflexed plate are longitudinally orientated, while the plantar aspect of
position. This will decrease the amount of dorsal scar tissue the plantar plate has horizontally orientated fibers that are con-
that forms, theoretically decreasing the rate of floating toes tinuous with the deep transverse intermetatarsal ligament [18].
that occur. The lateral edges of the plantar plate serve as the attachment of
Recently, there has been a considerable emphasis on the the accessory collateral ligament and the deep slips of the
correct diagnosis of the causative factor of metatarsalgia. plantar fascia. The plantar fascia has the additional role of pro-
Traditionally, it has been thought that the long metatarsal or viding the pulley-like structure that allows the flexor tendons
“unharmonious parabola” [24] is the sole problem. However, to provide plantarflexion to the MTP joint (Fig. 8.4) [17].
110 L.S. Weil and E.E. Klein

Fig. 8.3 (a) A cross section of a cadaver with a Weil metatarsal osteot- to the weight-bearing surface of the foot. (c) A cross section of a cadaver
omy performed that is angulated correctly. As the osteotomy is translated with a Weil metatarsal osteotomy performed that is angulated incorrectly.
proximally, it will follow the course of the thick black arrow, and planta- As the osteotomy is translated proximally, it will follow the course of the
rization will not occur if the metatarsal is shortened less than 3 mm. (b) thick black arrow and plantarization will occur
The intraoperative angle needed to achieve an osteotomy that is parallel

Fig. 8.4 (a) The plantar plate as it appears approaching it from the The slips of the plantar fascia are still attached to the plantar plate in
dorsum with longitudinal fibers in place. In this particular cadaveric this cadaveric specimen. This is a great illustration of the pulley system
specimen, the plantar plate attaches in two bundles. (b) The plantar that allows plantar flexion at the MTP joint
aspect of the plantar plate with the transversely orientated fibers. (c)
8  Lesser Metatarsal Osteotomy Complications 111

With understanding of the anatomy of the lesser MTP Management of Specific Complications
joint, it is clear that the plantar plate may have a role in lesser
MTP joint pain. Mann et al. [30] described a monoarticular Transverse Plane Deformities
synovitis of the lesser MTP joint capsule in 1985 and thought
that this may be a new diagnosis. Now, however, it is recognized Transverse plane deformities need to be properly diagnosed as
that the inflamed capsule and synovitis of the joint may a transverse plane deviation at the MTP joint and may represent
actually be a prodrome to a plantar plate tear [30, 31]. If this a partial lateral tear of the plantar plate, a tear of the collateral
problem is underdiagnosed or missed, an underlying osseous ligament, or a large interdigital neuroma (Fig. 8.5). The combi-
deformity [32] may lead to pathology in the plantar plate, nation of a positive drawer test on clinical exam coupled with
collateral ligaments, or both. Ninety-five percent of patients transverse plane deviation of the MTP joint >15° has been
with plantar plate pathology can be diagnosed clinically [25– shown to be associated with plantar plate injuries [26].
27] with the symptoms of pain, edema, and a positive drawer Advanced imaging can also be useful. Both ultrasound [33, 34]
sign. When you have a patient with a positive drawer sign and MRI [35, 36] have been shown to be useful to the diagnosis
and an increased lateral deviation of the third MTP joint on of plantar plate pathology with MRI being more useful in
AP radiographs, this should alert the astute clinician to the imaging of the collateral ligament structures [36].
potential presence of plantar plate pathology [26].

Fig. 8.5  Weight-bearing radiographs, clinical weight-bearing pre- and postoperative photographs, and intraoperative view of a patient that dem-
onstrates transverse plane deviation of the digit. This patient was found to have both plantar plate and collateral ligament pathology
112 L.S. Weil and E.E. Klein

The management of the transverse plane deformity at the a higher incidence of floating toes than when these two proce-
MTP joint is dependent on what is causing this deviation to dures are not combined [22].
occur. If the plantar plate is torn, surgical correction can be There are three distinct causes of floating toes. The first
undertaken from the dorsal approach to repair this problem cause of the floating toe is excessive shortening of the meta-
[21, 37]. Similarly, the collateral ligaments can be surgically tarsal and/or incorrect angulation of the osteotomy. As the
repaired through the same approach. A repair of the plantar capital fragment of the metatarsal is proximally translated,
plate can be augmented with capsule/tendon balancing pro- the axis of the joint is altered allowing the extensors to have
cedure or tendon transfer. a mechanical advantage over the weak, indirect attachment
The authors of this chapter and others have been using a of the flexor tendons. If the soft tissues around the joint (spe-
combined dorsal approach Weil osteotomy and plantar plate cifically the extensor tendons and the plantar plate) are not
repair since 2007 with consistent results [21]. Specifically addressed properly, floating toes can occur.
designed instrumentation has aided in the success of this The second cause of the floating toe is the presence of
approach to repair which avoids the problematic plantar inci- plantar plate pathology that is not addressed at the same time
sion, allows direct visualization of the plantar plate ­pathology, as the Weil osteotomy. As the plantar plate is the primary
and provides precise correction of the metatarsal position stabilizing structure of the lesser MTP joint, if this structure
with excellent tensioning of the plantar plate. is damaged, there will be instability of the MTP joint and
decreased plantarflexory strength of the MTP joint. This,
again, will allow the extensors a mechanical advantage as
Floating Toes stated above. The easiest way to correct this problem is to
correct the pathology at the plantar plate.
It is important to remember that central metatarsal osteoto- Third, floating toes can be caused by dorsal scar tissue and
mies (the Weil osteotomy, in particular) will alter the axis of adhesions that occur postoperatively. This scar tissue may be
the lesser MTP joint [23]. In proximally translating the meta- able to be prevented by aggressive postoperative brace and
tarsal head, the joint axis is moved proximally. This will allow physical therapy. If this does occur, however, an aggressive
the intrinsic muscles to act more as dorsiflexors than plan- tenotomy and capsulotomy of the scar tissue at the dorsal aspect
tarflexors [22, 24]. This may explain a part of the floating toe of the MTP joint with aggressive manipulation of the toe in the
problem. Interestingly, there is also a report in the literature direction of plantarflexion performed 6–12 months postopera-
that a PIPJ arthrodesis combined with an osteotomy may have tively can be helpful to treat this problem [22] (Fig. 8.6).

Fig. 8.6 (a) This patient is


12 weeks s/p plantar plate repair,
and the toe is slightly elevated
when the foot is loaded. (b) A
percutaneous tenotomy and
capsulotomy of the MTP joint. (c)
Plantarflexory manipulation of the
joint. (d) Toe purchase is obtained
8  Lesser Metatarsal Osteotomy Complications 113

Transfer Metatarsalgia of the lesser metatarsals. However, it has been described with
promising results for lesser metatarsal fractures that were not
Transfer metatarsalgia typically occurs from overshortening fixated initially [38]. Occasionally, patients may present with
or overelevation of the metatarsal at the time of surgery and a hypertrophic process that produces prominence and pain
has been cited by almost all procedural-type articles on this on the dorsum of the foot. This can be treated with resection
subject. If concerns about shortening exist during the index of the hypertrophic tissue.
procedure, it may be advisable to shorten the adjacent meta-
tarsals at that time [22].
Nonsurgical treatment of this problem can include Bunionette/Tailor’s Bunions
offloading the affected metatarsal head that is prominent.
However, if this fails to alleviate pain and symptoms, one There are a plethora of surgical procedures aimed at correcting
may be faced with the challenge of restoring the “harmoni- deformities of the fifth ray. Head [39], neck [40, 41], shaft [42–
ous parabola” [24]. To do this, a critical evaluation of AP and 46], base, and resectional procedures have all been described.
axial radiographs as well as a computerized footprint pres- Percutaneous [47, 48] and MIS procedures [49] have been
sure analysis (if available) must be undertaken. Once the described as well [50]. There is a classification system [43] that
apex of the deformity (i.e., the unharmonious metatarsal) is the Tailor’s bunion deformity can be (a) an enlarged lateral
identified, that metatarsal must be surgically altered in a way prominence, (b) a metaphyseal-diaphyseal flare/deviation, or (c)
that will restore the metatarsal parabola [51]. This may a widened 4–5 IM angle. The literature related to the description
require one or more osteotomies of the adjacent metatarsals. of surgical procedures for this deformity are limited in nature,
All previous discussion of the orientation and limitations of and many of these articles do not describe true complications of
the metatarsal osteotomy apply. this procedure. Therefore, principles from other portions of the
foot must be applied to this area.

Nonunion/Malunion
Under-Correction
This is a rare complication if this procedure is performed
properly. Preservation of the blood supply to the metatarsal One of the limitations of the ability of a procedure to correct
head (particularly maintaining the collateral ligament attach- a larger 4–5 intermetatarsal angle or a larger lateral deviation
ment to the metatarsal head) has been discussed. It is also angle is the width of the fifth metatarsal. This can lead to
important to avoid over-penetration of the plantar cortex of under-correcting the deformity with the index procedure.
the bone with the sagittal saw. There is a blood vessel that Larger deformities may require either a more proximal pro-
enters the bone plantarly. Although this artery is not the cedure or a procedure with a longer lever arm and more post-­
major source of blood flow to the distal aspect of the bone, it osteotomy osseous contact. If under-correction occurs and
is important to avoid damaging it. nonsurgical treatment does not alleviate the patient’s post-
Fixation of the osteotomy should follow AO principles. procedural symptoms, a reevaluation of the root of the prob-
This should prevent nonunion of the osteotomy. Observing lem needs to occur.
the osteotomy closing intraoperatively is important. In order If the recurrent problem is prominence of the metatarsal
to achieve this, plantarflexion of the toe with dorsal pressure head, a lateral or plantar condylectomy (depending on the
of the phalanx on the plantar aspect of the metatarsal head location of the problem) would likely be sufficient. However,
creates compression while fixation is performed. if one has under-corrected IM and/or lateral deviation angle,
Alternatively, one can use their thumb on the plantar surface a secondary osteotomy may be necessary. It may also be nec-
of the foot and provide dorsal compression of the osteotomy essary to perform a more proximal osteotomy that has more
site while the screw is being inserted. Additionally, the sur- ability to correct the remaining IM and/or lateral deviation
geon at the foot of the table can utilize a sesamoid or phalan- angles. Proximal osteotomies, however, may require a pro-
geal clamp to gently grasp the capital fragment and provide longed healing time as the blood flow at the base of the fifth
dorsal force, while the surgeon at the side of the table inserts metatarsal is notoriously poor.
the screw. If one point of fixation is not adequate, a second
point of fixation can be utilized. If a nonunion does occur,
one can consider many of the modalities discussed in the Shortened Ray
nonunion chapter of this text.
In cases of malunion, one may consider a revisional oste- Creating osteotomies of the fifth metatarsal will lead to
otomy with fixation that adheres to the AO guidelines. This shortening of the bone in some capacity. Osteotomies that
has not been specifically described for an elective osteotomy require removal of a segment of the bone shorten the fifth ray
114 L.S. Weil and E.E. Klein

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