Hello Podiatry colleagues.  I have used a dorsiflexory osteotomy to treat chronic Intractable plantar keratosis and/or ulcer of metatarsal head 2-4 in the past.  This involves v shaped incision into metatarsal neck with bone saw with apex distal at metatarsal neck going from dorsal/proximal to plantar/distal.  I transect the extensor tendons horizontally so they don't push the metatarsal head down.  I then move the metatarsal head up about 1/3 of height of metatarsal moving metatarsal superiorly and proximally, impact metatarsal head on metatarsal shaft, do not fixate it.  I've tried k-wires in past, but they fall out.  I then let the patient's walk on the surgery foot a limited amount with cane and surgical shoe for a month.  This usually works great and resolves IPK or ulcer.

My question is, I have 2 patients who have both had a complete hallux amputation and have both developed plantar 1st metatarsal head ulcer after hallux amputation.  One is diabetic, one is not.  Would a dorsiflexory osteotomy 1st metatarsal neck work?  I am concernced about 1st metatarsal head resection. I've tried that before for 1st met. head ulcers and have had metatarsal heads grow back, especially 1st metatarsal heads.  I've just never heard of this kind of surgery being done for 1st metatarsal heads and am wondering about the biomechanics of this.  Both patients moderately supinate the symptomatic side.

Does anyone have experience with 1st metatarsal neck dorsiflexory osteotomies?  Thank you.

  • Comments (12)
  • Page 1 of 2 Next
  • That is a good point Dr. Kass, thank you for your input.  I am trying him with diabetic shoes with metatarsal bar when working and orthowedge forefoot out shoe when not working for now.  I will work harder on convincing him to do cast before surgery, that is good advice.  

  • Dr Dale - I like you, you seem like a genuinely nice guy and concerned doctor. But, I would ask you respectfully to read your last few lines.....the attorneys are already salivating.....the guy will be compliant for surgery but he won't comply for conservative care? Then you punt the case and let him be someone else's headache.
  • Hello, sorry to be late in getting back to comments people left.  I use the arthrex complete plantar plate repair kit to fixate for weil osteotomy. This has snap off screws.  I had one non union, out of many I've done.  I don't often do weil ostetomy alone and apart from plantar plate repair, but maybe I should if it works well for IPK like other people have said.

    That is a good point about patient not being able to keep his dressing clean and dry after surgery if his job is dirty.  I think he should make the commitment and not work and do the total contact cast before surgery, but he's stubborn and insists he can't stop work right now.  He'd rather stop work for surgery and not the cast which doesn't make total sense to me.  

  • To answer an earlier question - I have done Weil osteotomy for ulcers but on lesser mets.
    You mention you had non unions. Do you fixate your Weil osteotomies?
  • "One of the patients I was thinking about for this surgery is a mechanic and his insurance won't pay for grafts and he can't do the total contact cast due to his feet getting dirty and wet often at work. I'm a big believer in the tcc for sure. I always look for equinus too in treating forefoot ulcers and have patients to achilles and hamstring stretches". - Dr. Dale

    Dr. Dale - I ask in the most respectful way. If the patient can't wear a total contact cast because his feet will get dirty and wet at work then how will the feet stay clean and dry after the surgery?


  • What is the forefoot to rearfoot relationship when the STJ is neutral and the MTJ is pronated; what is that relationship when the STJ is fully pronated and the MTJ is fully pronated? 

    What is the range of motion of the first metatarsal? 

    What is the range of motion of the MTJ around its long axis?

    You say the patient is supinated, does that mean that the STJ is supinated, or just the MTJ?  What do you believe to be the cause of the supination?

    Daryl

    How RU Daryl:

    Sorry, but I do not see the bearing of your questions in this case.

    The history suggests that the forefoot relationship is valgus in closed chain to the rearfoot but the surgeon already knows this without goniometry.

    Considering the complaint, the patient's forefoot is most likely pronated 1st met on 5th in closed chain. This means that it must be the rearfoot that is supinated.

    I would predict that the forefoot SERM-PERM Interval is low in this clinical history. How else would we get a 1st met lesion? Why do we need to get a time consuming and complicated measurement like the MTJ around its long axis that rarely is taken when I know the location of the wound?

    As a surgeon, I treated and supervised a hundred or more surgical cases involving 1st met wounds with success and I never needed nor saw import to take your goniometric measurements.

    I might use your measurements if Dr Bates question was: Where would a diabetic patient most likely get a forefoot wound?                                 But I have my 2 measurement functional foot typing to do that quicker and easier.

    Dennis

  • Quote:

    Hello Podiatry colleagues.  I have used a dorsiflexory osteotomy to treat chronic Intractable plantar keratosis and/or ulcer of metatarsal head 2-4 in the past.  This involves v shaped incision into metatarsal neck with bone saw with apex distal at metatarsal neck going from dorsal/proximal to plantar/distal.  I transect the extensor tendons horizontally so they don't push the metatarsal head down.  I then move the metatarsal head up about 1/3 of height of metatarsal moving metatarsal superiorly and proximally, impact metatarsal head on metatarsal shaft, do not fixate it.  I've tried k-wires in past, but they fall out.  I then let the patient's walk on the surgery foot a limited amount with cane and surgical shoe for a month.  This usually works great and resolves IPK or ulcer.

    My question is, I have 2 patients who have both had a complete hallux amputation and have both developed plantar 1st metatarsal head ulcer after hallux amputation.  One is diabetic, one is not.  Would a dorsiflexory osteotomy 1st metatarsal neck work?  I am concernced about 1st metatarsal head resection. I've tried that before for 1st met. head ulcers and have had metatarsal heads grow back, especially 1st metatarsal heads.  I've just never heard of this kind of surgery being done for 1st metatarsal heads and am wondering about the biomechanics of this.  Both patients moderately supinate the symptomatic side.

    Does anyone have experience with 1st metatarsal neck dorsiflexory osteotomies?  Thank you.


    One of the big questions I have is what are your goniometric measurements telling you:

    What is the RCSP and the NCSP? 

    What is the available ROM of the STJ? 

    What is the forefoot to rearfoot relationship when the STJ is neutral and the MTJ is pronated; what is that relationship when the STJ is fully pronated and the MTJ is fully pronated? 

    What is the range of motion of the first metatarsal? 

    What is the range of motion of the MTJ around its long axis?

    You say the patient is supinated, does that mean that the STJ is supinated, or just the MTJ?  What do you believe to be the cause of the supination?

    As I treat a lot of diabetics, I see this this particular problem commonly after a release of all the ligaments and tendons around the MTPJ.  This is why if I have to do a hallux amputation, I try to leave intact, if possible, all the capsular and tendon attachments of the MTPJ.

    Thanks for sharing,

    Daryl

  • I as a rule always fuse the pipj of the digit I perform the weil osteotomy and have not to date had any floating toe issues.
  • Thank you all for your input.  I have noticed a mild dorsal bump post operative operative with the dorsiflexory osteotomy, but I've never had any patient complain about it with shoe gear or otherwise.  They complain that their toe won't dorsiflex for a while, but the extensor tendons seem to eventually heal back together and toe dorsiflexion is regained at least partially.  

    I have heard of weil osteotomy for IPK or ulcer, do other doctors have success with it treating those issues?  I've had non-unions occur with that and it's difficult to get the osteotomy cut parallel to weightbearing surface if the toe is moderately to severely hammered I find if I'm not treating the hammertoe.  There's a concern about floating toe with weil also if you move met. head too far back which doesn't happen often though with me.

    I've heard of the peroneal longus lengthening for 1st met. head ulcers, but have never found any articles about it.  Are there sources I could read about that?

    One of the patients I was thinking about for this surgery is a mechanic and his insurance won't pay for grafts and he can't do the total contact cast due to his feet getting dirty and wet often at work. I'm a big believer in the tcc for sure.  I always look for equinus too in treating forefoot ulcers and have patients to achilles and hamstring stretches.  

    Thank you.

  • Dr. Dale - first, do no harm. Has a totol contact cast been tried? It's interesting as the literature states it to be the gold standard, yet I encounter few friends who use them. They do work.
    In the event you have, I would look to see if the patient has an equinis component. If so, you may be better off fixing that then a dfwo by the first met head.
  • Page 1 of 2 Next