In another thread about MIS for metatarsalgia, there is a discussion about the 'Leventen formula'. Who and what is the Leventen formula.

Ref blog: https://podiatry.com/etalk/index.php?topicid=20291#-1

To provide for a better, more reliable outcome, following metatarsal osteotomy for metatarsalgia, and to reduce the incidence of later additional surgery Leventen devised a surgical approach to pre-emptively also address the adjacent metatarsals. This is based on the primary location.  

Leventen's approach, which some now refer to as the 'Leventen Formula' is named after Edward O. Leventen, MD. Dr. Leventen is an orthopedic surgeon (see picture) who, in 1990, published a paper in the journal of Foot & Ankle, entitled 'Distal Metatarsal Osteotomy for Intractable plantar keratoses'.

In this article, Leventen reports on the outcome of 21 feet, with an average follow up of 31 months. Outcome measures include a subjective assessment of pain & function. This is a non-validated outcome measure tool. (Not unusual for the year of publication). A clinical examination was performed for callus, stiffness, sensory changes, metatarsalgia. Harris mat impression was obtained and x-ray's performed.

After the surgery 15 feet were rated good to excellent. 6 feet rated poor to fair.

In this paper he advocates a particular strategy to know which of the metatarsal need to be addressed surgically, to both resolve the IPK and to limit also the risk of a possible transfer lesion to an adjacent metatarsal.

Although Dr. Leventen does not describe MIS surgery, in his paper, this strategic approach is advocated by some MIS surgeons.

Dr. Leventen performs conventional open surgery. Unlike the MIS surgeon, who perform a through-and-through osteotomy, Dr. Leventen's technique uses a partial osteotomy (closing wedge-type configuration with manual osteoclasis w/out fixation) to elevate the metatarsal head, modelled after the orthopedic surgeon, Wolf (1973).

Wolf would confine his attention to the affected metatarsal only. Leventen observed that many patients would subsequently require additional surgery to manage the problem of new pain and transfer lesions.

web-Leventen


  • Comments (3)
  • Weil osteotomy in the treatment of central metatarsalgia 

    M.A. Ruiz Ibán, M. de Antonio Fernández, A. Galeote Rivas and M. de Frías González. Hospital Universitario Ramón y Cajal. Department of Orthopedic and Trauma Surgery. Madrid. Spain.

    Rev Ortop Traumatol. 2006;50:30-7

    Purpose.

    To assess the results of Weil osteotomy in the treatment and prevention of overload metatarsalgia in the foot’s central metatarsals.

    Materials and methods. A retrospective examination was performed of the first forty-two consecutive patients who had been subjected to one or more Weil osteotomies for the treatment or prophylaxis of central metatarsalgia. Two subjects refused to be included in the study, which means that only 48 feet were included from 40 subjects who were subjected to 96 osteotomies. All clinical records were studied and the patients were interviewed in order to determine the aesthetic, radiographical and functional results obtained on the basis of the American Orthopedic Foot and Ankle Society (AOFAS)’s lesser metatarsal and interphalangeal bones’ score.

    Results. 87.5% of results were considered good or excellent from the functional point of view, with 81.3% being considered good or excellent from the aesthetic point of view. The final score as measured by the AOFAS score was 85 ± 12.6 points. Neither infections nor osseointegration delays were noted. One of the patients was reoperated in the immediate post-op because of a fracture and in four cases the osteosynthesis material had to be retrieved. 66.7% of feel presented with a mild metatarsophalangeal mobility defect. In four patients this defect was serious.

    Conclusions. Weil osteotomy is a safe and appropriate technique to address central metatarsalgia. It has drawbacks that stem from intolerance to the osteosynthesis material and to metatarsophalangeal mobility defects.

  • For a greater understanding why there may be a poor outcome following a metatarsal osteotomy (irrespective of the preferred surgical approach) for IPK's (and related skin lesions) the reader is directed to this blog item:

    https://www.podiatry.com/etalk/index.php?topicid=20815#-1

  • Quote:

    Nice info Fellner.  

    Thomas Bauer did a nice study on 118 patients with mean followup of 26 mo.  He used the Leventeen formula with MIS PMO.  

    Only 4 patients had transfer pain.  Only 2 had marked stiffness.  

    This is a better result than the gold standard Weil osteotomy which has frequent MPJ stiffness and difficulty with restoraton of the distal met arch  seen with multiple fixated met oteotomies.  

    I have performed many Weil and step up osteotomies. The PMO is far superior IMO.


    Don Peacock

     

     

     

    Thomas Bauer's work was reported in a textbook, but without any reference towards a published article.  If you know differently please let me know - I will be interested to read the article, if this exists. Self reported outcomes, from the author cannot pass the peer review process due to the risk of bias. 

    As for the outcomes reported for the Weil osteotomy, I would ask which articles you wish to refer to. I am not necessarily disagreeing, since there is certainly a reported incidence of failure after Weil's procedure but this deserves closer scrutiny. At this time, there is only one published article reporting on the Leventen method (from the author) and this has its' own fair share of failures.