Current Concepts in Metatarsal Osteotomies

Abstract

Background: Metatarsal load-bearing properties, length, and first ray pathology have challenged the successful treatment of metatarsalgia. Surgical techniques without internal fixation have accounted for high incidences of nonunion and pseudoarthrosis, whereas excessive bone resection causes a shift in metatarsal parabola, leading to alternative stress patterns and complications. The Weil, midshaft segmental, and the asymmetric V osteotomies are shortening procedures used for developing reliability and predictability in the treatment of metatarsalgia. Results: Galluch et al retrospectively reviewed cases in 102 feet treated by midshaft osteotomy (126 osteotomies) and reported a nonunion rate of 0.8%. Asymmetric V osteotomy was performed on 40 metatarsals, and studies reported no recurrent metatarsalgia, transfer lesions, or malunions. Trnka et al compared Helal osteotomy, a distal oblique osteotomy without internal fixation, with Weil distal osteotomy in patients who had metatarsalgia secondary to lesser metatarsophalangeal (MTP) dislocation. In 30 patients (15 Weil osteotomies, 25 metatarsals; 15 Helal osteotomies, 22 metatarsals), those managed with Weil osteotomy had higher satisfaction (P = 0.049), lower incidence of recurrent metatarsalgia (0% vs 27%, P = 0.107), and better MTP alignment (21 of 25 metatarsals, 84%, vs 8 of 22 metatarsals, 36%; P = 0.002). Conclusions: Weil and asymmetric V osteotomies are effective means to enhance stability and control shortening but can be technically demanding. Midshaft osteotomy is a simple procedure, with excellent union rates, preservation of MTP motion, and stable management of shortening. These procedures all improve the predictability of metatarsal shortening and elevation, decreasing complications, and enhance quality of life. First ray stabilization procedures, gastrocnemius recession, and hammertoe realignments may all influence outcome because metatarsalgia rarely occurs as an isolated condition.