Callus Distraction Osteogenesis for Brachymetatarsia, Retrospective Review of 91 Metatarsals
Deena Horn DPM AACFAS1,2, John Doolan DPM FACFAS1,2, Adam Cirlincione FACFAS DPM 1, Joseph Larsen DPM FACFAS1,2
PURPOSE
The goal of this study is to show the use of distraction
osteogenesis using external fixator in a large retrospective review
and discuss the benefits along with the complications that may
result.
Figure 1: Pre-operative Measurements
of Brachymetatarsia Bilateral
Figure 2: Left Foot Prior to Surgical Correction and
Right Foot After Surgical Correction
METHODOLOGY & HYPOTHESIS
A chart review was performed in (JD) office for all patients
requiring surgery for brachymetatarsia for May 2009 to May 2015.
123 metatarsal were identified through the search however 20
patients were excluded because bone block was performed to
correct the brachymetatarsia, 10 metatarsals did not have adequate
follow-up and 2 metatarsals had a different surgical technique. 91
metatarsal were included in the study in 65 subjects. The mean
patient’s age was 30 (ranging from 16-66). 5 metatarsal (5.5%) in 3
patients were males and the rest of the metatarsal were females
(96%) females. Brachymetatarsia was present to the 4th metatarsal
in 93% of the patients with six 3rd metatarsal. 49 metatarsal were
present on the right side and 42 on the left. To determine all the
patients with brachymetatarsia a review as done through electronic
radiograph system. The average lengths were measured from the
pre-operative radiographs based on the parabola (Figure 1). All the
Figure 2: Application of External Fixator
measurements were performed by D.H. from the head of
metatarsal to where the metatarsal length should be based on the
parabolic arch used electronic radiograph system. The subjects were
followed for minimum of 1 year. The average follow up was 3.84
years.
The hypothesis we pose is that lengthening a metatarsal using callus
distaction would be a safe, effective way to correct brachymetarasia.
1ProHealth Care Associates
2 Attending Foot and Ankle Surgeons, NYP/Weill Cornell Medical Center
PROCEDURE
A dorsal 4 cm incision was made overlying the effected metatarsal
extending from the MTPJ to the metataphyseal diaphysial junction. The
incision was deepened using sharp and blunt dissection and MTPJ was
identified. Using a 15 blade and McGlamory elevator the MTPJ was
released. If necessary at this time a tenotomy was performed to
release the flexor tendon. A 0.062 K wire was then placed
anterograde through the distal aspect of the toe into the metatarsal
head to keep the toe in adequate position throughout the lengthening
cycle. At this point, the metaphyseal diaphysial area was identified. The
BIOMET DFS Mini Fixator and Lengthener® pins inserted into the
metatarsal. The first 1.6 cortical bone screw was placed perpendicular
to long axis of the thickest part of the metatarsal head and the second
pin placed proximally using the parallel guide. Two more pin, 3.0
tapered mini cortical bone screw, were then placed proximal at the
metaphyseal diaphysial junction in the metatarsal base. The osteotomy
was then performed at the metaphyseal diaphysial junction of the 4th
metatarsal. The DFS Mini-lengthener was distracted intra operatively to
ensure completeness of osteotomy. The distal and proximal fragments
were then reapproximated. Patients were placed in a posterior splint
and were to remain non-weight bearing for 1-2 weeks. Patients were
seen at post op day 10 (7-14) and instructed to do one quarter turn 3
x per day. Patients were seen every week until adequate length, which
had been measured pre-operatively, was obtained. This was based on
both clinical and radiographic findings. After lengthening had occurred,
which last approximately 1 month, patient was left in the frame for
double the amount of time in order for the bone to consolidate. The
K-wire through the MTPJ was removed throughout different points in
patient’s post operative period ranging from 1 month post operatively
to at the time of removal of the external fixator. Patients were able to
be weight bearing as tolerated in a surgical shoe for the remained of
the post-operative period. All patients had a bone stimulator (Exogen)
at some point in the peri-operative period.
Figure 3: Distraction
Osteogenesis Radiograph
LITERATURE REVIEW
Figure 6: Seven Years Post
Operatively Clinical Picture
Figure 5: Six Weeks s/p Removal
of External Fixator
Brachymetatarsia is defined by one short metatarsal that ends 5
mm more proximal to the parabolic arc (1,2,3). It is a rare
condition with an incidence of 0.02-0.05% of the population; it
affects females 25:1 (2).
There are many different causes including congenital, post-
traumatic, post surgical or it can be linked to disease such as
Down’s syndrome, Apert’s syndrome, Albright’s osteodystrophy,
sickle-cell anemia, poliomyelitis (1,2). It is thought that the most
common cause is idiopathic congenital from early closure of the
epiphyseal plate.
Brachymetatarsia is more than a cosmetic issue with deformity
commonly causing pain and metatarsalgia when untreated. Many
patient’s discussed that they would not wear sandals in fear of
having someone see their feet. Until this present article, the largest
study was by Shim and Park showing the use of distraction
osteogenesis in 17 patients with 39 metatarsal bones (5).
One stage metatarsal lengthening is often discussed in the
literature because better patient compliance and shorter period of
union. The disadvantage of one stage lengthening, that the
metatarsal can not be lengthened passed 10 mm secondary to
resulting neurovascular compromise (4,5,6).
Previously, distraction Osteogenesis has been described in the
literature prior with good results. However, never at this
magnitude. Jones et al in a systemic review of all literature from
level IV-V evidence found a combined number of 388 metatarsal.
The major complications was 12.62% with minor complications of
48.45%. In addition, the mean length obtained from callus
distraction was 17.5 mm. Honsy et al in 2015 in Foot and Ankle
International looked at 11 patients that underwent callus
distraction for brachymetatarsia with excellent results according to
the Japanese Society for Surgery of the Foot standard rating
system (2). Ferrandez looked at 3 patients also had excellent
results with distraction osteogenesis (7).
RESULTS
A total of 91 metatarsals in 65 patients met the inclusion criteria. The
average age at the time of surgery was 30 ± 10. The patient cohort
was 86 females (95%) and 5 males (5%) with 49 right metatarsal (53%)
and 42 left metatarsal (46.5%). Most subjects had no past medical
history: 1 subject had Diabetes, 5 HTN, 2 Multiple sclerosis, 1 Diabetes
insipidus, 2 Hypothyroidism, 1 GERD. 22 patients (33%) had bilateral
surgeries. Adjunct procedures at the time of surgery include two
Lapidus bunionectomy, STJ implant, 4 Austin bunionectomy, 1 modified
McBride bunionectomy and 5 patients had toe grafts placed. The
metatarsal were lengthened 15.24 ±3.40. The mean follow up of 3.84 ±
0.07 years.
There were a total of 32 infections (35%). Most of them superficial pin
tract irritation/infection which subsided after one round of oral
antibiotics. One patient had superficial blistering post op and three
patients had wound dehiscence; one requiring surgical debridement and
application of wound graft.
Twenty three patients (25%) required revisional surgery. Four patient
(4%) required bone grafting secondary to non-union and plating of the
non-union. Two patients (2%) had a fracture of the 4th metatarsal head in
the first month post operatively and required emergent ORIF and
grafting of the space at that time.
Three MTPJ implants were placed 2-3 years after surgery secondary to
arthritis and pain. 10 patients required tenotomy and capsulotomy for
dorsal subluxation of the digit. Two digital bone block distraction
arthrodesis were performed at the PIPJ of the effected metatarsal. One
subject had a loss of the digit. This patient had an osteotomy and
external fixator applied, when patient came for second follow up patient
had not started the distraction and required a secondary procedure
because the osteotomy had already started to consolidate.
Of the 91 metatarsal, 41 metatarsal were able to be contacted via
phone. Subjects were ask there overall satisfaction with the procedure
and would they do it again. Subjects were informed that 10 extremely
happy (VAS 10/10) and would no hesitate for to the have the procedure
performed again and 0 was completely dissatisfied and they wish they
had never done it . The mean VAS was 7.8± 2.6. One patient described
the surgery as “life changing because it gave her more confidence.” Many
subjects had similar complaints: 5 reported a plantar-flexed digit “toe
flopping down,” 5 reported to decrease motion at the MTPJ, 3
subjected reported to not having the toe long enough, and 2 reported
to not being happy with their scar. One subject stated there was
numbness in the toe and one said they were not happy with the
procedure because they could not wear heels.
Figure 7: Images of Double Brachymetatasia Repair in 3rd and 4th Metatarsals
DISCUSSION
Distraction Osteogenesis with callus formation is a safe and effective
way to treat brachymetatarsia. Distraction Osteogenesis has been
described in the literature prior with good results however never at this
magnitude. The complications in this study are similar to that of prior
studies including stiffness of the joint, pin site infection and longer
periods of bone union (2). However Honsy et al had pin site infections
in 9/11 (82%) of their patients in comparison to the 35% reported in
this study. Baek and Chung discussed two fractures, four subjected with
MTPJ stiffness. Stiffness was also recored by Lee et al in 13/27 feet and
subluxation was present in 23 % of subject in Shim and Park. Lamm et al
discuss complications associated with lengthening of metatarsal including
overlying, nonunion, delayed union, premature consolidation, MTPJ
subluxation, MTPJ stiffness, scarring, pin site infection, shortening and toe
contractors (11).
It is discussed in the literature, regarding the psychological component
associate with the surgery (2, 12). Many patients that were called
discussed the process as lengthy and time consuming. The patients are
being followed in the office weekly until out to length and then closely
monitored for pin tract infections. It is important to discuss with your
patients prior to the surgery to make sure they understand the potential
risks.
We did not specifically look at time to consolidation in your patients
secondary to documented however all patients feel in a range between
45-75 days with the mini-rail in place. As discussed above, we have
patient’s lengthen 0.75 mm daily (three turns) versus the standard 1 mm
per day. It is thought that other authors, Lamm et al came to similar
conclusion, and are only lengthening 0.5 mm/day (6). In addition, this is a
retrospective study that only has subjective findings in 45% of the
metatarsals involved. The authors are looking to perform a prospective
study with pre and post operative lengthening measurements.
The advantages of this study it shows the brachymetatarsia repair using
callus distraction is a safe and effective treatment looking at a very large
sample size.
In conclusion, callus distraction with an external fixator is a safe and
effective way to length a short metatarsal. The patient should be
adequately educated prior to the surgery so that have a good
understanding of the length and possible complications that can occur.
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