Christopher K Bromley,DPM discusses the etiology and pathomechanics related to lesser metatarsalgia. Dr Bromley also reviews current surgical options as well as some take home points when evaluating and managing patients with lesser metatarsalgia.
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TAPE STARTS – [00:00]
Bromley: Now I’m going to give you a 30 minute talk on lesser metatarsalgia surgical approaches and we’ll have the box lunches available, so instead of as your schedule says 30-minute break for lunch, but I like you do if you would please grab a box of lunch and come right back in because we’re going to keep moving, and we can get you out of here early, okay. So that’s going to happen, so and I appreciate you’re here and we’re going to reward you by getting you out of here early.
Alright, so we’re going to talk a little bit about lesser metatarsalgia. Disclosure, I have unfortunately no financial interest in any other companies that we’re going to review there is an educational grant that typically supports these CME talks.
It helps if we start the timer because then – I get yelled at for going a little short on the hammertoe lecture, so [Indecipherable] [0:00:58] the timer so as we move forward. Alright, so the goal of today’s lecture is to understand some of the etiology of lesser metatarsal pathology. I will review the surgical options we have and take home some pearls for your surgical success.
So as we know, typically metatarsal pain has to do with, it can be a number of things, the first metatarsal can be short or long, second or third, and they’re going to be some sort of a biomechanical component. Typically somebody is going to pronate and they end up with a sort of a forefoot supinatus, and this is going to put more weight under the second or third could be iatrogenic, patient has had bunionectomy and they’ve ended up with an elevates where it's short patient may have also some MTPJ subluxation. I often will tell patients as they come in with hammertoe, they are like “why does it hurt so much, why do I get this painful callous,” and I show them that all the meat in padding that you’re supposed to walk on is now up in the interspace.
When we have a conversation with everybody about, aging and collagen, and make some sort of some self-deprecating thing about getting old, even as I said they may have had failed foot surgery.
So is the pathology present with or without involvement of the plantar plate. Typically, there was dorsiflexion deformity with flexor plate intact, subluxation could also instability with the plantar plate being disrupted. I use ultrasound in my office quite a bit and I take pride in being able to show the patients what kind of shape their flexor structures are in do they have a true plate defect.
So what osteotomies are there, when I finished my training in 1992 the sort of the typical osteotomy of the day was either somebody was just doing a transverse osteotomy or at the time of a V-osteotomy and you kind of floated it up and you hope like how that it ended up where you wanted to be and not too high and too short. As things went on, the Weil osteotomy has sort of become the more popular, lesser metatarsal osteotomy. In our practice, typically nowadays we will talk about the fixation opportunities. I like doing them, I think they as our surgery progressed from just doing an arthroplasty for toe and hoping maybe to stabilize it's over the K wire. As we evolved in surgery and we started looking at PIPJ arthrodesis, which we talked about this morning, then you had to go back and address the metatarsal because you weren’t using the K wire anymore and you weren’t hoping like how that the toe would stay where you wanted it to be.
And I think back to some of my mentors who argue, I mentioned this morning was the one that sort of taught me right after my residency about pre-dislocation syndrome and he talked about what happens in the hammertoe, how it becomes unstable and what to look for, and I think that there is always an opportunity to learn even when we’re standing up here on the podium.
So what are our current methods of fixation. For a while in my hands, I typically use 10 or 12mm snap-off screw. There are people who will use screws or plates, we’ll talk about some of the plating. A cerclage wire is sort of falling out of favor and as I mentioned early on the V-osteotomy, which we didn’t use any fixation for. I actually asked the other day for some cerclage wire I was a doing a fifth metatarsal fracture with a plate and it was a locking plate and as I got a last locking screw and it all went to shit and I asked if they had ceclage wire and they give me that golden retriever look like what is that [laughs], so I did ask him to order some just in case we could have for the next case.
So what happens with some of the complications when we get into lesser metatarsal, so you can have a poor fixation. I did a Weil not long ago where I did the snap-off screw and there is that moment where you’re hoping the screw will go in and as the head of the screw hits the bone and it will snap off, well this one didn’t snap off it just kept going through the bone, which was not optimal, so we obviously took that out and went to. In addition, floating or a cockup toe, I mentioned this morning, I haven’t had one of these in a while, but I did have a patient where we did PIPJ arthrodesis successfully, and she came in like three months later after she’d been in South America and that second toe was floating and as I said you this morning I don’t use a McGlamry elevator whenever I’m at the second MTP joint.
So I should have remembered because I did a bunionectomy on her years ago and she came in about eight or nine weeks after the surgery with a varus. And I was able to do some soft tissue releases and some balancing and some bracing and we got that toe back over. And I should have remembered her, but now I get to do a flexor plate repair on her. There is a little bit of flexor plate discussion in this lecture and there’s going to be a lecture on plantar plate repair by Dr. Trepel this afternoon.
Obviously, slow healing, poor healing I think it really comes down to your surgical approach. I think you’re remembering that this is a very small bone and it has very poor blood flow, you need to be really gentle with the bone, with your dissection and with your fixation, obviously very important.
So what are the problems with the Weil, obviously if you have trouble with fixation, you can transfer the plantar head laterally. You can have difficulty with the fixation and rotation, you can have some intra-articular issue in the floating toe. How many people here have done Weil’s and ended up with a lot of scar tissue and contracture around the second MTP that they really struggle with, anybody besides me, yeah. So along came the MSP a few years ago, the MSP if you’re not familiar with it, it’s a plate that goes onto the metatarsal and you perform an oblique osteotomy and you’re staying away from the MTP joint altogether and I will tell you that in my hands anytime, although I like a while if I’m doing a PIPJ fusion and then I want to go ahead and address the metatarsal. But I really like being able to stay away from the MTP joint with correction. It’s a very stable construct, you can adjust the length, you don’t have any plantar shifting, and the key with this particular procedure as we get into is it's extra-articular and I think there’s something to be said for that.
So this is what is what it looks like, it’s a metatarsal diaphyseal osteotomy, provides sagittal plane coaxial shortening, it’s very low profile and it has a cutting guide to it and a plantar keel, which I will show you that helps with the biplane strength and it’s a very stable construct for early weight-bearing. You’re not going to have any displacement, as I said these are sort of osteotomy guides and superior fixation, let me get into that.
So this is what the plate looks like, you’ve got some really easy hand pieces, you got a driver and a drill bit, essentially what you’re going to make your incision back here. I typically stay away from the MPJ, you want to be sort of right in the middle of the metatarsal and what you’re going to do is, there’s a right and a left kit and you’re going to go ahead and do your dissection staying away from the MTP joint. And you’re going to go ahead and place it on the bone, there’s a drill guide and they’ve got, for your pin, you’ve got little measurements and you want to get the plate anchored and use your C-arm. As I said you’re staying away from the joint, you get this distal screw in place and once you get that distal screw in place, you’re going to use a locking screw in that distal hole, tighten it down a little bit and then you’re going to go proximally. And this keel, which is going to be on the medial part of the second, you want to make sure that that keel is lined up right next to the bone. So that when you do that that helps make sure that your drill holes in your screw fixation are going to be right in the middle of the second metatarsal. If you don’t do that, what happens is your screw -- this is obviously not a very wide bone and what happens is your screw will not be dead center.
So once you get the distal screw and you put this proximal screw in the screw and then once she get that done then you go ahead and perform the osteotomy right with your sagittal saw right through that cut guide. So once you do that, now you can adjust the length of the metatarsal and decide exactly how long you want it. Once you get it, you can see, you can move it back and forth and what I do then is I kind of clamp it in place with a bone clamp or it’s a small enough bone or a woman you can just use like a just little Alice clamp I just stay away from the sharp bone clamp because I don’t want to crack it and just very gently hold it and you go ahead and put your wire through, this would be your third screw and that’s going to secure the plate and you can see the drill guide and a very easy use and it’s a built-in osteotomy, which I think is easy. It’s very stable fixation. We weight-bear these patients right away, there’s two locking and two cortical screws, very easy.
I think the key to this procedure is that it stays away from the MTP joint and that gets rid of all that scarring and stiffness that you have when you get involved in the joint. So this is the case of a 71-year-old physician, 11 years status post some surgery at second MTP. You can see the transverse plane deformity and as I said you want to stay away from the joint, you’re working back here in this area, you can see the placement of the device making sure that the keel is against the bone using your C-arm to make sure you’re right where you want to be. We got a distal screw and you start getting things lined up, good exposure, this is a really great area to do work at. Obviously, you’re going to be cognizant of your neurovascular structures, but using a plate over here on the first metatarsal or fifth, those plates can be issue in reference to shoe.
But the second metatarsal’s got a fair amount of padding over top of it, soft tissue protection and that plate doesn’t present to be a problem. You can see in this video, you can see you kind of moving that back and forth and you can adjust the length.
So once you get it to where you want to do, obviously you’re shortening it to the proper length you’re not too short compared to the third, but that’s very, very helpful. And then we go ahead and put the other screws in and we’re going to adjust and then tighten down to make sure. So this is before, you can see where it is and you can see we’re stayed well behind the MTP joint. You see we've got a nice metatarsal parabola now compared to what we had before and you can see without a K-wire that toes are looking pretty good.
There are some other cases, a lot of stuff going on here. We’ve done some other bunion work and we put the plate here. So here’s some other x-rays of that patient, you can see the plate and then the length. The screws are bicortical and the alignment is good, again we are staying away from that MTP joint.
Alright, so other things that can cause lesser metatarsalgia. Obviously, patient can have an osteochondral defect from trauma, Freiberg's infraction or the role of the flexor plate. So osteoarthritis, what are our surgical options, debridement. In a lecture I gave the other day, we talked about the use of debridement with an allograft where we use the debridement technique or use like a 0.35 wire in a lesser met. I don’t use the nano effects, which we talked about the other day. That’s that in-and-out tool we use that in the ankle and on the metatarsal. It’s a little big to be banging on a lesser met with the nano effects. We use the 0.35 wire very slow. Metatarsal resurfacing, they are good option, but if you’ve never done a metatarsal resurfacing lesser met is not one you should start with, you should start with the first metatarsal until you feel comfortable. Obviously, there’s some allografts available, total joint replacement and then metatarsal head resection in a older, more sedentary patient.
So here’s the patient who’s got chronic regional pain. They’ve got the other issues that are present Freiberg's, you can see, this is just not a happy joint. What are the options for Freiberg's, obviously debridement as we talked about. Here’s a case you can see a pretty nasty looking joint. We talked about this before on the first metatarsal. For the lesser, this is a little big. I’ll typically use a 0.35 K-wire very slow. There is the hemicap for a lesser metatarsal, but as I said, you can see on the x-ray, this is a small bone, small margin for error, the wire placement is everything. When you get the wire in here -- what I typically do with these is I put the wire in 2 or 3 millimeters make sure on the DP and the lateral you’re exactly where you need to be and then the drilling and reaming proceeds and you can go ahead and put the cap on.
There are still physicians who do phalangeal base implants, I don’t. There’s still people who use elastic implants I don’t, but they are an option. So we talked a little bit about this, so what’s going on with the plantar plate. Obviously, this is a very important structure in the foot. When things go wrong and it starts to fail, we can obviously get a floating toe or subluxation and we start to see that transverse plane deformity. As I said earlier today, I’m not a McGlamry elevator fan. I believe that you should maintain these attachments and not de-glove the metatarsal. There’s nutrient arteries under here and the last thing you want to do is start debriding that stuff away, a very important structure.
This is the CPR plate repair system where you can see, you know, go ahead and perform the metatarsal osteotomy. We won’t spend too much time on this because there’s going to be couple of other lectures, but this particular device shows that a crosswire. This is not my favorite, but it is a good procedure, but you’ve got to push that metatarsal back, so that you can get exposure, debride the rest of it off and do good suture technique, much like Marie William said this morning. I don’t use any non-absorbable suture because like many of you I found it to be pretty reactive. So I just use a 2-0 Vicryl suture with this. And then once you get your repair, then you can go ahead and fix your metatarsal osteotomy. If you have an opportunity of big enough bone, two small snap-off screws are always better than one to prevent rotation. This is a new system, the gravity plate repair system, which is a little bit easier to use. I think it’s easier for me in my hands. What we do is obviously get everything out of the way and their particular technique is that the screwed holes are parallel. So when you drill these through you don’t have to worry about the two holes converging like he did in the other system, so this is a little bit easier system to use, the instrumentation is much easier, you can just put this through and grab your suture and pull it right out, a very easy system overall.
So one of the things that -- Low Weil [phonetic] I didn’t get to see Low this particular meeting, but when I met him I’ve been using his Weil device to help my patients. We start using it in these patients in the pre-op setting. So we give it to them and train them how to use it, so that we can lengthen some of those dorsal contractures. Before we do PIPJ arthrodesis, we’ve got an MTP component and then we’re using it obviously in the postop space.
Typical postop protocol for us is that they want to be full weight-bearing when we do MTP or metatarsal surgery. I’m typically getting them out of shoes, out of the boot at about somewhere between four and six weeks with it orthotic and a plan to offload that as it heals. But if you’ve never used one of these Weil splints, I will tell you that it’s a very valuable tool in your toolbox.
So, in summary, obviously the current advances in lesser metatarsal surgical fixation give you better control. I have found that although I do a Weil well and I like the snap-off screws, I've gone more to staying away from the second MPJ and using the MSP plate because I find that the plate really controls, I can adjust the length, I don’t have to worry about rotation and I’m staying away from the MTP. Every time I get talked into doing a Weil or I may be decided that’s an option, I always kick myself later because I’ve got this ball of scar tissue around the second MTP and then I’m fighting that for months and months and months. So I think if you’ve never done one of the MSP plates, I think it’s a really great tool in our toolbox and I’ve never had an issue with anybody having any prominence or pain over the plate. The key with using that plate is obviously to make sure that the keel is up against the metatarsal, so it doesn’t rotate that gives you easy fixation, look using your C-arm to make sure that your alignment is where it needs to be and then when you have the opportunity use the Weil splint in the pre-op as well as post-op space to get them to elongate those contracted scar tissue.
So overall that sort of does a wrap-up for us on lesser metatarsal. I think in my practice using the surgical treatment in addition to the PIPJ arthrodesis as we talked about this morning for that seems to work out best.
Do you have any questions before we take a run out to grab a sandwich or lunch? Yes sir.
Male Speaker: [Indecipherable] [0:20:18]
Bromley: No. Yes it’s an oblique osteotomy, so it’s basically going to just slide back on itself, let me show you.
Male Speaker: [Indecipherable] [0:20:38]
Bromley: It just slides proximally, yes it didn’t deviate at all. I think I’ll show it to you.
Male Speaker: Then the cut on the plane looks angle.
Bromley: Its oblique, it’s an oblique, yes it’s an oblique osteotomy.
Male Speaker: And on the dorsal part of the metatarsal right?
Bromley: I’m sorry.
Male Speaker: You’re placing that on the dorsal part of the metatarsal?
Bromley: Yes, so it’s basically going to slide back like an oblique. Remember you’re going to lose bone from performing the osteotomy, so there’s a couple of millimeters -- you can adjust this up to 3 mm in length, 1 to 3. So the nice thing is as I said when we looked at the x-ray, you can see here, you see where this transverse plane was before and you see how long this is compared to the first, and then you can see -- obviously the x-rays aren’t exactly correct, but you can see the length pattern now.
Male Speaker: It almost looking like a little wedge of bone.
Bromley: Just a cut, it’s just a cut with a saw. It goes right through the guide. So there is your cut guide, so you’re going to come out here. Now the other pearl that I didn’t mention before is that if you get too distal with this, one of the first ones I ever did I was a little too distal and the distal part of my osteotomy was pretty close to the metatarsal head, so you definitely want to stay more proximal to make sure that you don’t get into that. The case went fine, it was very stable, but I talked to myself “mm-hmm,” it could be a little more proximal. Another question.
Male Speaker: Conservative treatment for straight cut outs, the second met head cut out on the orthotic, anything conservative.
Bromley: Of course yes, always that goes without saying. I mean one of the things we do best in podiatry is all the conservative stuff. So when people come in we always give them this the same talk, which is these are your alternatives, this is what we’re going to do to your shoe, this is what we’re get you an orthotic, obviously we’re always going to do that before we do anything surgically. Any other question, yes.
Female Speaker: So you’re speaking of like you’ve seen any – what are you using to -- what are you using surgically to dissect that area or not dissect that area are you?
Bromley: That’s a great question, intrinsically the flexor plate and all the collateral ligaments and then the neurovascular supply, one of their nutrient arteries is right behind that metatarsal right at that surgical neck. So I don’t dissect anything plantarly. If they have if, you know, did a good normal dissection to get the MTP open, if you’re going to be doing a flexor plate repair or a Weil, but I’m very, very, very gentle and the last thing I want to do is use a McGlamry. I mean I was taught, we always do this is what we do every time, but I don’t do it anymore. The only time I use a McGlamry is if I’m doing a first MTP re-surfacing and it’s like a late stage III and they’ve got some sesamoid involvement is I’ll typically go in and try to free those up because I know even if I re-surface the metatarsal, those sesamoids are going to be my limiting factor for range of motion later. That’s the only place I’m using it, but I stay away from using it on a lesser met because it’s -- why would you shove that back in there and remove the proximal attachment of the whole plate structure, it doesn’t make any sense to me. And I want to leave that alone and address the deformity where it is, is the metatarsal too long compared to everything else, what’s going on with the joint in reference to stability, but the less of the dissection I did with the McGlamry the less of the floating toe stuff I saw other than the woman I just saw who had the varus with a few years ago. And I didn’t McGlamry her at all, all I did is a PIPJ arthrodesis. I didn’t even touch her MTP joint, but I think I didn’t appreciate what condition her flexor plate was in.
Female Speaker: [Indecipherable] [0:24:31]
Bromley: Yes those are my -- so the question was, what about the transverse plane. So like and we were talking about the case before that’s one of my least favorite things to treat, I hate treating those. So typically what I’ll do is if I’ve got somebody who says I really don’t like the position of my second toe, usually those are involved you’ve got somebody with metadductus or you see the all the lesser toes are coming over and then they got the bunion, that’s my least favorite thing to treat. I mean I’d rather treat almost anything besides that, but if they do if it’s very mild and it’s just happening, typically I will obviously in the conservative space use the Weil split to figure out if it’s isolated to second or second and third, and then if we get into doing a procedure and I’ve got to get into that joint. If it’s moving medially, I’ll take a 67 blade and just do a like a medial capsular release leaving the lateral and the intrinsics in place and then obviously balancing the soft tissue, but the less often I have to going into the MTP joint, the better off because you just get a lot of scar. Good question, any other questions? Well you guys have been awesome, so we have a – if you could do me a favor…
TAPE ENDS [0:25:49]