Brachymetatarsia: a surgical treatment

Callus distraction for brachymetatarsia - A comparison between an internal device and the external fixator

BACKGROUND

Symptomatic patients with severe brachymetatarsia are commonly treated with callus distraction using external mini-fixator (EF) or internal device (ID). This study points out advantages and limitations of both methods comparing clinical and radiographical parameters.

METHODS

Retrospective analysis of 21 metatarsal bones in twelve patients. Twelve metatarsals were treated with ID (Genos Mini), nine with EF (MiniRail).

RESULTS

Mean lengthening distance was 17.3 mm using EF and 11.7 mm using ID (p = 0.016). Adverse results were observed in 89% of metatarsals treated with EF and in 33% treated with ID (p = 0.011). Postoperative surgical intervention was required in 33% using EF compared to 0% using ID (p = 0.031). Mean total German Foot Function Index (FFI-T) improved from 49 to 33 using EF and from 47 to 22 using ID (p < 0.001).

CONCLUSION

CD is a reliable surgical treatment for BMT. Surgeons should be aware of implant-related advantages and complications when counseling patients about treatment options.

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

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.

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

Objective: Brachymetatarsia is defined as the pathological shortening of a metatarsal bone, which can cause cosmetic problems and pain in the forefoot. The main surgical treatment options are: extension osteotomy, interposition of a bone graft, and callus distraction. Usually, a bone graft from the iliac crest is used for the interposition osteotomy. The operative technique of graft extraction from the fibula has not been described in the literature yet. Methods: Eight feet with brachymetatarsia in 5 patients were evaluated retrospectively. The minimum follow-up period was 2 years. Via a dorsal V/Y skin incision, a central osteotomy on the metatarsal bone was done. A graft was obtained from the anterior fibula. The graft was inserted and fixed by a locking plate. Additional soft tissue procedures were done. Results: We had bony consolidation in all cases. The mean extension was 9.01 mm (5.49 to 12.54 mm). This corresponded to a mean 20.3% extension of the entire metatarsal. High patient satisfaction as well as high satisfaction regarding the cosmetic results were achieved. There were no postoperative complications. The range of motion of the metatarsal-phalangeal joint IV was 20% less preoperative in terms of plantar flexion. Standing up on tiptoes was possible in all patients postoperatively. One patient reported mild symptoms after sports activities. Conclusions: Because of its anatomy the graft adapts to the metatarsal IV bone. As our study showed, harvesting from the distal fibula causes no functional restriction. In terms of wound and bone healing as well as pain symptoms, this method should be considered as an alternative to the standard iliac graft.

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).

[Treatment options for brachymetatarsia]

Brachymetatarsia can be congenital, idiopathic or secondary and describes an abnormal shortening of a metatarsal bone. The indications for treatment are not only due to cosmesis. The shortening of a ray changes the biomechanics of the foot and can lead to metatarsalgia. A frequent clinical feature is dorsal dislocation of a toe causing painful shoe conflict and disturbed proprioception. There are three main options for operative correction: lengthening osteotomy, interposition of a tricortical bone and gradual lengthening by callus distraction. While one stage lengthening procedures such as osteotomy and interposition are more appropriate for correction of moderate length deficiencies, the callus distraction method is more suitable for larger elongation. Common to all procedures is a long-term treatment with a high risk of different complications whereby patient compliance can be problematical.

Case report: a modified 1-stage technique for the treatment of brachymetatarsia

Brachymetatarsia is an abnormal shortening of a metatarsal. It causes disruption of the normal metatarsal parabola, resulting in metatarsalgia, calluses and dislocation of the digits. Patients often express discontent with the appearance of their feet. Lengthening by distraction osteogenesis and 1-stage intercalary bone grafting procedures are the mainstays of operative treatment. We present a modified 1-stage technique, combining the use of a Chevron osteotomy of the fourth metatarsal with shortening osteotomies of the second and third metatarsals. Bone removed from the third metatarsal was used to lengthen the fourth. The Chevron segments provided mediolateral, dorsoplantar, and rotational stability. The technique was used on both feet of 1 patient. The mean increase in AOFAS score was 34.5 (right foot, 46; left foot, 23.) There were no complications. A 1-stage technique does not require an external fixator or postoperative manipulation and has a quicker healing time. Taking the bone graft from neighboring metatarsals decreases the discrepancy between metatarsal lengths. A smaller increase in the length of the fourth ray is then required, and the chance of neurovascular injury as a result of soft-tissue stretching is minimized. This technique allows restoration of the metatarsal parabola and provides good correction, immediate stability, and good integration.

LEVELS OF EVIDENCE

Therapeutic Level IV, Case Study.

Problems, obstacles, and complications of metatarsal lengthening for the treatment of brachymetatarsia

Metatarsal lengthening by distraction osteogenesis is a challenging procedure that is associated with various adverse results. This article presents and classifies adverse results arising from metatarsal lengthening. Our premise of classification is that not all adverse results that occur secondary to distraction osteogenesis of the metatarsal are true complications that affect the final outcome, but rather are problems and obstacles that present hurdles to completion of treatment. Our classification differentiates among problems, obstacles, and complications during metatarsal lengthening with external fixation. The cause of each adverse result is also discussed and clinical and surgical pearls to avoid these problems, obstacles, and complications are presented.

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.

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.

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

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.

Changes in blood flow during one stage lengthening of bone: an experimental study in rats

Distraction osteogenesis is a well-accepted method of bone lengthening. Its disadvantages, however, are that it requires an external fixator and takes a long time. One-stage lengthening therefore offers certain advantages. A first point of reference for the safe limits of this procedure might be the changes of blood flow, and this is also the crucial factor in deciding on the appropriate method of lengthening, particularly where the hand or foot is involved. Using a laser Doppler flowmeter we measured blood flow in the dorsum of the foot after using bilateral minimonofixators to lengthen the tibias of 15 Sprague-Dawley rats. They were lengthened in four stages: stage 0 (before lengthening); stage I--12.5%; stage II--25%; and stage III--31.25% of lengthening. The blood flow during stage I decreased to 79% compared to that of stage 0; 16% during stage II; and 1% during stage III. This study suggests that the maximal permissible extent of lengthening might be less than a quarter according to the blood flow as suggested by this animal model.

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.

Bone grafting for reconstructive osteotomies of the foot

This article presents a literature review of the use of bone grafts in reconstructive osteotomies of the foot. Applications of this techniques, specifically for the calcaneus, cuneiforms, and metatarsal bones, are discussed. Surgical treatment of various conditions such as pes valgus, metatarsus adductus, hallux abducto valgus, and brachymetatarsia are highlighted.

Congenital brachymetatarsia: three cases

We report on three cases with congenital brachymetatarsia, one with bilateral affectation, together with the results of a lengthening of the short metatarsal bones by progressive axial distraction using an external minifixator. The method proved to be easy to implement, permitting immediate functionality of the ankle and early load bearing. The immediate results (cosmetic) and later findings (functional) were excellent in all three cases.