Distraction osteogenesis for congenitally short lesser metatarsals

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.

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

Brachymetatarsia: One-stage Versus Two-Stage Procedures

Brachymetatarsia is a rare deformity with controversial clinical presentation. Multiple acute and gradual lengthening surgical techniques have been described for correction of this type of foot deformity. All techniques try to create a better appearance, facilitate shoeing, or solve possible transfer metatarsalgia. Either acute lengthening (1-stage procedure) or gradual lengthening (2 stages) is selected based on the patient's deformities, concerns, and clinical needs.

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.

Callus Distraction Versus Single-Stage Lengthening With Bone Graft for Treatment of Brachymetatarsia: A Systematic Review

Brachymetatarsia deformity is a cosmetically displeasing anomaly that can become physically symptomatic. The surgical techniques most commonly used to repair the anomaly include single-stage lengthening with a bone graft, callus distraction, or a combination of bone grafting and callus distraction. A systematic review of the published data was performed to compare the outcomes of these 3 surgical procedures. A total of 61 studies reporting the use of callus distraction or single-stage lengthening, or both, for the treatment of brachymetatarsia were included in the present review. The incidence of major postoperative complications after callus distraction, single-stage lengthening, and the combination procedure was 49 (12.62%), 13 (3.72%), and 3 (33.33%), respectively. The number of minor complications with callus distraction, single-stage lengthening, and the combination procedure was 152 (39.18%), 55 (15.76%), and 1 (11.11%); the mean percentage of the original length achieved was 37.36%, 25.98% and 36.00%; and the mean length achieved was 17.5, 13.2, and 14.0 mm, respectively. The healing index (mo/cm) and healing time was 2.31 and 16.04 weeks, 1.90 and 9.35 weeks, and 3.93 and 14.62 weeks for callus distraction, single-stage lengthening, and the combination procedure, respectively. Our findings indicate that the callus distraction technique is associated with greater length gained but results in greater complication rates and requires almost twice the time to heal. Single-stage lengthening with a bone graft was associated with fewer complications and faster healing times than callus distraction but with lesser gains in length. From the information reported in the studies we reviewed, the prevalence of bilateral brachymetatarsia was 44.52%, and the female/male ratio was 13.7:1. Both of these findings seem to contradict the usual data given (72% for bilateral brachymetatarsia and a female/male ratio of 25:1).

Metatarsal lengthening by callotasis in adults with first brachymetatarsia

BACKGROUND

Brachymetatarsia is a rare clinical entity that presents a challenging problem for surgeons. One-stage lengthening with an autologous bone graft has been preferred for metatarsals that require a limited lengthening. With a gradual lengthening of metatarsals, callus distraction (callotasis) can achieve a greater length gain and a concomitant lengthening of the soft tissue. This article presents results of callotasis for adults with first brachymetatarsia.

METHODS

The outcomes of nine cases of first brachymetatarsia in five adult patients who underwent metatarsal lengthening by callotasis between March 1999 and February 2005 were retrospectively reviewed and analyzed.

RESULTS

The average length gain was 16.4 mm and the average lengthening percentage was 43.7%. In addition, the average healing index was calculated as 3.8 months/cm, which was higher than that reported previously in the fourth brachymetatarsia.

CONCLUSION

It was concluded that the period of bony consolidation following callotasis is longer in the first brachymetatarsia than in the fourth brachymetatarsia. Presumably, this might be because of the anatomically larger osteotomized cut surface and its weight-bearing function.

Lengthening of the midfoot in a case of lower-extremity hemimelia

Hemimelia of the lower limb belongs to the group of congenital deficiency disorders. The clinical spectrum ranges from minimal shortening of the long bones to severe deficiencies of the extremities. Several etiologies, such as X-rays or drugs, have been implicated to be responsible for hemimelia. In the present report the clinical course and the long-term follow-up of a patient with transverse terminal hemimelia of the left foot at the level of the basis of the metatarsals is described. Due to frequent episodes of pain, development of pressure sores, and an increasing psychological burden, operative intervention consisting of a lengthening procedure using an Ilizarov fixator was indicated. Long-term outcome was good; the patient is now able to painlessly wear conventional shoes and displays a normal gait pattern.

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.

Correction of longitudinal epiphyseal bracket disease with external fixation: a case report with 6-year follow-up period

Longitudinal epiphyseal bracket disease is a rare congenital abnormality of the tubular bones. This syndrome eventually leads to progressive shortening and angular deformity of the involved bone. When longitudinal epiphyseal bracket disease affects the first metatarsal, a short trapezoidal shaped metatarsal is noted radiographically. We present the case of a 9-year-old patient with longitudinal epiphyseal bracket disease of the first metatarsal. The abnormality was surgically treated by bracket osteotomy with callus distraction before physeal closure. At 6 years of follow-up, the patient displayed a relatively normal looking cosmetic foot compared with the contralateral foot. A mild residual hallux varus was noted, with maintenance of the forefoot parabola. Surgical correction resulted in alteration of the first intermetatarsal angle and the first metatarsophalangeal angle. The first intermetatarsal angle decreased from a preoperative value of -30° to a postoperative value of 10°. The first metatarsophalangeal angle decreased from a preoperative value of 36° of hallux varus to a postoperative value of 4°. The length of the first metatarsal was restored compared with that of the contralateral limb and was slightly elongated. The present case study demonstrates that early surgical correction with callus distraction of an ossified abnormal bracket before physeal closure, a relatively simple procedure, can restore longitudinal growth and correct the angular deformity.

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.

Percutaneous distraction osteogenesis for treatment of brachymetatarsia

Brachymetatarsia is not an unusual deformity and is often associated with functional and cosmetic issues that warrant surgical reconstruction. Lengthening of the affected metatarsal can be undertaken on an acute basis in a single operative procedure that involves the use of a bone graft or by means of gradual callus distraction. Because of the risk of metatarsophalangeal joint malalignment, it is important for the surgeon to take steps to stabilize the joint during the lengthening process. In this report, a percutaneous method of callus distraction for repair of brachymetatarsia and maintenance of metatarsophalangeal joint alignment is presented.

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.

Complications associated with distraction osteogenesis for the correction of brachymetatarsia: a review of five procedures

BACKGROUND

Congenital brachymetatarsia is often treated with callus distraction. This technique is associated with a variety of complications. We investigated complications encountered in treatment of brachymetatarsia in four female patients and reviewed adjunctive procedures performed to treat these complications.

METHODS

We reviewed five distraction osteogenesis procedures performed in four female patients with congenital shortening of the fourth metatarsal over a 3-year period. Serial radiographs were obtained weekly until bone consolidation was achieved, at which time the external fixator was removed. Follow-up ranged from 5 to 10 months.

RESULTS

Three patients (four metatarsals) were satisfied with the cosmetic and functional outcomes of their procedure. One patient was dissatisfied with the cosmetic result owing to a short digit from a short proximal phalanx but was completely functional and resumed all of her normal activities. Complications associated with callus distraction were decreased range of motion and stiffness at the metatarsophalangeal joint, flexion deformity of the digit, angulation of the metatarsal, prolonged distraction time due to pain, fracture of the bone callus, pin-site infection, and an undesirable cosmetic appearance due to a short proximal phalanx. Adjunctive procedures were needed in some of these cases and yielded good results.

CONCLUSIONS

Callus distraction is an effective treatment for congenital shortening of the fourth metatarsal, but the procedure is associated with a number of complications. Because most patients proceed with surgery for cosmetic reasons, it is important to present the possible complications and the adjunctive surgical procedures that may be necessary for a desirable outcome.

Treatment of brachymetatarsia by distraction osteogenesis

Metatarsal lengthening by distraction osteogenesis was performed on 17 brachymetatarsia patients with 39 metatarsal bones. To lengthen the first metatarsal in an attempt to prevent development of varus deformity of the hindfoot after lengthening, horizontal lengthening in the anterior direction was performed rather than lengthening through the anatomical axis. In addition, care was taken to ensure that the fourth metatarsal bone screw did not interpose with the fifth extensor tendon during the fourth metatarsal lengthening. Lengthening was successful except in 1 case with mean lengthening of 19.5 mm (48.8%) for the first metatarsal and 17.1 mm (36.2%) for the fourth metatarsal. Because of joint stiffness, plantar capsulotomy was performed on 7 cases, 6 of which had been previously operated on bilaterally. Varus deformity of the hindfoot after the first metatarsal lengthening and entrapment of the fifth extensor tendon after the fourth metatarsal lengthening was not detected in any case.

External fixation for the foot and ankle in children

During the last decade, external fixation for the pediatric foot and ankle has evolved as a result of advances in technology (eg, Taylor spatial frame, hydroxyapatite-coated external fixator pins) and preoperative deformity planning. Although complications are common, most are minor and can be addressed nonoperatively while treatment continues. This article reviews the indications and applications of external fixation for soft tissue contractures, idiopathic and teratologic clubfoot, osteotomies, metatarsal lengthening, tibial lengthening, and foot and ankle trauma.

Complications of distraction osteogenesis in short first metatarsals

The authors analyzed the results and complications of metatarsal lengthening in short first metatarsals by distraction osteogenesis. There were 13 first metatarsal lengthenings in eight patients. Mean age was 18.8 years and the average percentage of lengthening was 49.2%. The average healing index was 72.4 days/cm. The major complication was cavus foot, which was noticed in four feet. All great toes showed some loss of motion at metatarsophalangeal (MP) joint. Other complications were hallux valgus, angulation of the metatarsals, and pin tract infection each in two feet. The functional score according to the American Orthopedic Foot and Ankle Society (AOFAS) hallux MP joint, interphalangeal joint scale was excellent in 11 and good in 2. All patients were satisfied with the procedure. To avoid potential complications such as MP joint subluxation, cavus foot, and hallux valgus, the first metatarsal lengthening should not exceed 50% of the original length.

Low-intensity ultrasound enhances maturation of callus after segmental transport

The purpose of this study was to determine whether low-intensity ultrasound can be used to enhance callus maturation. Fifteen-millimeter bone defects at the metatarsal bones of sheep were treated with a segmental bone transport for 16 days. The callus formations in the bone defects were allowed to mature for 63 days before the animals were sacrificed. Eighteen sheep were operated on and divided into two groups. One group was treated with low-intensity ultrasound for 20 minutes per day, whereas the other group served as an untreated control group. Biomechanical tests after removal of the metatarsals showed significantly higher axial compression stiffness and significantly higher indentation stiffness of callus tissue in the healing zone in the group treated with ultrasound. Also, histologic analysis of the cortical defect zone showed significantly more callus formation and more active zones of endochondral ossification in the group treated with ultrasound. Stimulation of callus maturation by ultrasound is possible, similar to stimulation of fresh fracture healing, and may be used to shorten clinical treatment times.

Brachymetatarsia

Brachymetatarsia is a rare clinical entity that presents a complicated case to the treating surgeon. One-stage lengthening procedures with a variety of biologic and synthetic implants are preferred for metatarsals that only need to be lengthened up to 15 mm, whereas gradual lengthening allows for greater length gain and concomitant lengthening of the soft tissues. Adjacent metatarsal shortening may be used in conjunction with lengthening procedures to restore the parabolic arc of the metatarsal heads. Management should be tailored to the patient's individual deformity and expectations. Individualization of surgical techniques and patient selection criteria can result in a cosmetic, functional result that is satisfactory to the clinician and the patient.

Metatarsal lengthening by callus distraction for brachymetatarsia

Twelve metatarsal lengthening procedures by callus distraction were performed in seven patients with brachymetatarsia. The mean age at the time of the surgery was 12.0 years (range, 11.1-14.5 years). The mean duration of follow-up was 5.2 years (range, 1.2-13.5 years). The bones were lengthened at a rate of 0.7 mm/day by a mean of 20 mm (range, 15-30 mm), which was 45% of their original length (range, 37-61%). The mean healing index was 73 days/cm (range, 41-98 days/cm). Corrective shortening osteotomy was performed in one case in which the metatarsophalangeal joint was dislocated due to excessive lengthening. In 10 of the remaining 11 cases, joint stiffness, narrowing of the joint space and some degree of plantar subluxation of the metatarsophalangeal joint were observed during distraction, but these were gradually resolved without either elongation of the tendon or metatarsophalangeal joint fixation with Kirschner wire.

Distraction osteogenesis for treatment of premature physeal closure and shortening of the third and fourth metatarsals of a dog

A 4-month-old Siberian husky was presented for a history of lameness of the left hind limb. Physical and radiographic examination revealed a 1-cm shortening of metatarsals III and IV, with subsequent hyperextension of the digits on the left hind paw. A circular external skeletal fixator was used to accomplish distraction osteogenesis in both metatarsals over a period of 15 days. Treatment was successful in restoring appropriate length of the metatarsals and in resolution of the lameness. At 6 and 12 months after surgery, the owner reported that the dog was ambulating normally and had no complications related to the surgery.

Metatarsal lengthening

Metatarsal lengthening for brachymetatarsia is a good procedure that can improve appearance and function. There are risks to these procedures, which should be understood thoroughly.

Brachymetatarsia: congenitally short third and fourth metatarsals treated by distraction lengthening--a case report and literature summary

Brachymetatarsia is an uncommon condition, and when present, it is usually asymptomatic. A case report demonstrating the use of distraction lengthening for symptomatic multiple congenital short metatarsals is presented. A 15-year-old female with congenital short third and fourth metatarsals was treated for painful transfer lesions under the second and fifth metatarsal heads and a secondary hallux valgus deformity. Surgical correction with a chevron osteotomy, soft tissue reconstruction of the second toe, and distraction lengthening of the third and fourth metatarsals was performed. Three years after treatment, the patient has an excellent clinical correction, with no evidence of recurrent transfer lesions. To our knowledge, this is the first report demonstrating the use of distraction lengthening without supplemental bone graft for multiple short metatarsals in a single extremity.

Treatment of brachymetatarsia by the callus distraction method

Brachymetatarsia is not an uncommon congenital foot disorder that is due to a premature closure of the ephiphyseal plate. The literature has numerous surgical procedures for the correction of this problem. In recent years, the callus distraction technique described by ilizarov has been utilized for this problem. This is a retrospective study of the use of the callus distraction technique for the correction of congenitally short metatarsal. This series included six feet in six female patients, all with a short fourth metatarsal. Preoperative complaints were metatarsalgia and/or cosmesis. A noncircular, uniplanar axial fixation device was utilized for fixation and distraction. The fixator was put in place prior to the metatarsal osteotomy. Static fixation was for a period of 5-7 days before distraction was begun. The metatarsal was lengthened 0.5 mm two times a day, or 1 mm per day. The time to end point ranged from 45 to 70 days, followed by another 6-8 weeks of static immobilization. The preoperative metatarsal length ranged from 3.5 to 4.2 cm. The end stage metatarsal length ranged from 4.7 to 6.3 cm, with an average increase in length of 1.68 cm. As compared to other techniques described in the medical literature, the callus distraction technique has its own unique set of advantages and disadvantages.