Chapter 28: Lesser MetatarsalSurgeryAnatomy (Metatarsals 2-3-4)Differential Diagnosis of MetatarsalgiaSurgical Treatment of the IPKLesser Metatarsal Joint ReplacementPanmetatarsal Head ResectionMetatarsus AdductusFreiberg's DiseaseTailor's BunionSplayfootBrachymetatarsia (Brachymetopody)Skewfoot

LESSER METATARSAL SURGERYThe central 3 metatarsals are usually grouped together because they do not have individual axes of motion.

Anatomy (Metatarsals 2-3-4)1. The deep transverse metatarsal ligament attaches to the plantar pad and head of the central metatarsals on both sides. This affords greater stability to the metatarsals 2-4 rather than to metatarsals 1 & 5

2. The plantar plate attaches to the metatarsal heads and the extensor hood runs from dorsal to plantar to join at the inferior junction of the hood, capsule, and deep transmetatarsal ligament

3. Blood supply to a long bone is via 3 sources: a. Nutrientb. Metaphyseal: In the metaphyseal region, there is an additional advantage of having metaphyseal vessels adding a vascular system to bonec. Periosteal: overlap entirely with the nutrient artery and so in most places there is at least two supplies4. Surgical neck is distal to the anatomical neck, and the condyles are

directly plantar to the flare between the two

5. There is a normal declination of the metatarsal of approximately 15°

Differential Diagnosis of Metatasalgia,1. Local factors:a. Stress fracturesb. Neuroma or neuritis c. Intermetatarsal bursitis d. Freiberg's infractione. Biomechanical factors:i. Abnormality of metatarsal parabola resulting in plantarflexion,shortening or elevation of a metatarsalii. Pes planus or pes cavusg. Tumorsh. Arthritis (local as well as systemic) i. Sesamoiditisj. Tendonitis

2. Referred or systemic etiology:a. Compression neuropathy of spinal cord L5-S3 b. Compression neuropathy of tarsal tunnel c. Peripheral neuropathyd. Ischemia

Surgical Treatment of the IPKOne should try to biomechanically evaluate why a lesion is present so that the chances for return are reduced after correction of both the actual lesion and the underlying cause.1. Etiology of plantar lesions (metatarsals 2-4):a. Biomechanical forces: Equinus, rearfoot varus, FF varus/valgus, adductory twistb. Hammertoe syndrome: Causes a retrograde plantarflexory force on the metatarsal head. As the MPJ dorsiflexes due to muscular imbalances around that articulation, the dorsal sling mechanism causes the proximal phalanx to dorsiflex and apply a downward vector to the metatarsal. As time progresses, there is a soft tissue contracture of the area and the metatarsal is exposed to abnormal stresses c. Atrophy or displacement of the plantar fat pad d. Long or short metatarsal (even at the same declination angle) e. Sagittal misalignment (abnormal declination angle): Abnormal plantarflexed position, abnormal adjacent metatarsal, hypermobility f. Abnormal bone shape (prominent plantar condyle)

2. Etiology of plantar lesions (metatarsal 5):a. Biomechanical: Rearfoot varus, rigid forefoot valgus, forefoot varusb. Sagittal malalignment: Abnormal plantarflexed 5th metatarsal, plantarflexed cuboid, dorsiflexed 4th metatarsal

c. Congenitally long 5th metatarsal or short 4th metatarsald. Abnormal bone shape or size (prominent plantar lateral condyle) e. Fat pad atrophy

3. Differential diagnosis:a. Verruca plantaris: pinpoint bleeding, usually not directly on weightbearing area, fast development, skin lines surround the lesion b. Inclusion cyst: history of trauma (foreign body, puncture) c. Scar tissue (history of trauma)d. Foreign body

4. Preoperative considerations:a. Mark the lesion with a x-ray opaque markerb. Take x-ray in the angle and base of gait in full weight-bearing c. Evaluate the metatarsal parabola (141.5°) d. Check the axial view to evaluate the condylese. Look at the morphology of the metatarsal head and the relative position of the fat pad

5. Summary of procedures: Can be done at the head, shaft, or the. base of the metatarsal.It is a good idea to enucleate the lesion prior to, or at the time of surgery to hasten recovery of the plantar skin.a. Procedures at the neck or head:i. Percutaneous metaphyseal osteotomy (PMO): Osteotomy at the metaphyseal region where the capital fragment is

dorsiflexed Done so that the capital fragment is forced to the appropriate level when

walking The deep transverse ligament helps hold the the head in the correct

position, not allowing it to dislocate dorsally The cut is dorsal-distal to plantar-proximal to avoid the condyles and lift

the entire distal segment (fixation at the proper level) ii. Transverse osteotomy: Similar to the PMO but done visually May be modified to shorten a metatarsal or fixated to control position iii. "V" osteotomy: Done at the anatomical neck Gives good transverse and frontal plane stability due to the "V" cut Cut must include the condyles Apex is distal so the head and the phalanx act as one unit, so the head is

not free to dislocate Ambulation is allowed to force the head into the appropriate position Must debride or excochleate the lesion preop to avoid forcing the head too

high May impact on the shaft to control positioniv. Dorsiflexory wedge osteotomy (DFWO): A tilt up osteotomy•Done at the anatomical neck or at the base (1 cm from the metatarsal-

cuneiform joint) Apex is plantar and the base-is dorsal Shortens the metatarsal Must be proximal to the condyles at the neck Must fixate Ambulation in a Reese® shoev. Arcuate osteotomy: Bone at the neck or base Special blade is needed (1800 arc) Allows for transverse and sagittal motion Must be fixatedvi. McKeever peg-in-hole: Shortens the metatarsal significantly Technically difficultvii. Cylindrical stepdown osteotomy: For long metatarsal A cylindrical segment of bone is removed to cause shortening of the

metatarsal that needs fixation and NWBviii. Chevron: A double "V" osteotomy with section removed used to shorten the

metatarsal Fixation must be used Cannot take too much bone due to the soft tissue attempting to maintain

length Cuts must be parallel and congruent ix. Osteoclasis: Surgical fracture at the anatomical neck by forceps Semi-free floating head No heat from the power equipment, therefore, little bone necrosisx. Metatarsal head resection and condylectomy: Helpful for subluxed and/or deformed joint Joint is basically removedxi. Metatarsal head resection: For deformed or destroyed MPJ Shortens the ray Allows contracture of the toe but the pain from the lesion disappears Best done in the elderly Close and purse string the capsulexii. Plantar condylectomy: Open the MPJ and elevate the metatarsal head to allow access to the

plantar condyles Condyles are resected and area rasped smooth Osteoarthritis can develop and joint limitus may develop as disruption of

the integrity of the MPJ is necessary No bone healing needed, therefore, early ambulation

b. Procedures at the shaft:i. Giannestras step down osteotomy:

For a long metatarsal Z" shortening of the metatarsal that needs fixation

c. Procedures at the base:i. Cresentic: As described above ii. DFWO: As described above

6. Complications of metatarsal osteotomies:a. Transfer lesions develop (so try not to overcorrect by indiscriminateelevation)b. Dorsal bump develops from too much elevation without havingremodeled the headc. Floating toe develops from destroying the internal cubic content of thejointd. Non-union occurs if ischemia is produced or no fixation or stabilizationof the osteotomy site existse. Flail toe from transection of the musculotendonous tissues surroundingstructuresf. Dislocation of the metatarsal head and deformed position of the heador toeg. Edemah. Return of the original deformity due to not enough elevation of themetatarsal segment

Lesser Metatarsal Joint Replacement1. Indications:a. Inflammatory arthritides: RAb. Degenerative arthrosis secondary to: i. Osteochondral fractures ii. Osteochondritis dissecans iii. Orthopedic deformity iv. Joint subluxation v. Malaligned fractures of the foot vi. Traumavii. Previous surgeryviii. Congenital deformityc. Congenital deformity- Brachymetatarsiad. Flail toese. Floating toesf. Revisional surgery

2. Types:a. Swanson flexible hinge toe implantb. Sgarlato double-stem cup implant (hinge avoided) c. Swanson condylar implant

3. Surgical technique:a. Lazy "S" Incision over the MPJ (less skin contracture)

b. Linear or "U" shaped capsulotomyc. Preoperative soft tissue contractures eliminated via extensor/flexor tenotomies and/or plantar plate/hood released. Bony resection (mostly metatarsal head)e. Reaming the medullary canals (caution in the proximal phalanx)f. Sgarlato recommends centralizing the flexor tendons via a drill hole in the plantar portion of the phalangeal base and attaching the tendon by sutureg. Check fit with a sizerh. Flush copiouslyi. Wound closed in layers

4. Complications:a. Implant instability: Pistoning can occur from removal of too much bone as well as axial rotation of the implantb. Implant failure: Mechanical stress can produce microfragmentation with migration of the silicone particles into the lymphatic system. With this there will be obvious loss of function and possible deformity c. Foreign body reactiond. Osteochondritis dissecans: From excessive stripping of the periosteum and resultant avasular necrosise. Detritic synovitis reaction: The surgical area will become red and swollen with a chronic low grade pain. Once infection is ruled out the patient can be treated with NSAIDS or remove the implant device f. Infection: Implant must be removed and not replaced for at least 6 months to one year. If gram negative infection was present, implant should not be replaced for longer period of time if at all g. Pistoning of the implant into cancellous bone (if implant chosen is too small)h. Chronic edemai. Fracture of the base of the proximal phalanx

5. Contraindications:a. Severe osteoporosis of the involved bones (seen with RA)b. History of a prior joint infection within the last 6 months c. History of allergic reaction to implant materiald. Medically compromised patient (diabetic neuropathy, Charcot joint)

Panmetatarsal Head ResectionThis procedure can be gratifying but must be performed only when the proper criteria are met.1. Historical:a. Hoffman (1911): Transverse plantar approachb. McKeever (1952): Dorsal longitudinal approachc. Clayton (1963): Transverse dorsal approach for metatarsal head and phalangeal base resections

2. Preoperative signs:a. IPK's under most metatarsal heads

b. Atrophy of plantar fat padc. Ability to palpate prominent metatarsal heads d. Dorsally contracted toes at the MPJ'se. Possible contracted toes and proximal interphalangeal joint or distal interphalangeal joint with associated lesionsf. Range of motion at the MPJ may be limited or painful or may be absent g. Range of motion of the MPJ may elicit crepitus h. Signs of degenerative disease and deformity i. Patient ambulates with an apropulsive type gait j. Ulceration of sub-metatarsal head area

3. Preoperative symptoms:a. Moderate to severe pain on the plantar aspect of the forefoot when the patient ambulates with or without shoes b. Painful multiple hyperkeratotic lesions c. Painful plantar ulcerations under the metatarsal heads area d. Patient may complain of painful dorsally contracted toes when wearing shoese. Patient complains of pain when most of the MPJ's are moved f. Patient may complain that the toes cannot be straightened g. History of metabolic disease (RA, psoriatic arthritis, etc.)

4. Preoperative x-ray evaluation:a. Evidence of DJDb. Dorsally contracted MPJc. Most of the MPJ's show evidence of DJDd. Bone loss evident secondary to severe DJD e. Proliferation of bone at the MPJ'sf. Loss of normal joint spaceg. Cystic and erosive changes in the metatarsal heads h. Generalized osteoporosisi. Moderate to severe angulation deformity of the toes and metatarsals may be present

5. Surgical procedure of choice:a. 5 dorsal linear incisions: 3 dorsal linear incisions; or transverse incision b. Maintain normal metatarsal parabola: The second is the longest, followed by the 1st and third, followed by the 4th, and finally the 5th c. The 1st metatarsal head is resected more medially than laterally d. The lesser extensor tendons are usually tenotomizede. Angulate the dorso-plantar cuts on all the metatarsal heads in order to remove more bone plantarly than dorsallyg. Release the tourniquet prior to closing to prevent hematoma formation h. K-wires can be used (helps eliminate the need for syndactylism) i. Betadine soaked gauze can prevent postoperative edema and infection and helps keep the toes in an aligned position

6. Advantages:

a. Eliminates painful MPJ'sb. Ability to ambulate without painc. Allows patient to wear regular shoesd. Allows reduction of dorsally contracted toes in most cases e. Elimination of plantar pressure points

7. Disadvantages:a. Loss of propulsive gaitb. Flail toes postoperativelyc. Incidence of hematoma formation with resulting fibrosis d. Destroys the function of the MTPJ's e. Loss of digital stability

Metatarsus Adductus1. Clinical evaluation:a. Adducted forefoot in the transverse plane with the apex of the deformity at LisFranc's jointb. Medial border concave with a deep vertical skin crease c. Hallux widely separated from the 2nd toe d. The lesser digits will be adducted at their basese. Occasionally the abductor hallucis may be palpably taut

2. Radiographic evaluation:

NOTE* if one excises a large amount of the metatarsal and one is already dealing with short toes (especially the 5th), then syndactylism will aid in achieving some stability of the area distally in the forefoot. This procedure can be an adjunct to panmetatarsal head resection

a. Increase in metatarsus adductus angle (greater than 200)

3. Indications for surgerya. Failure to respond to conservative treatmentb. Residual deformity after treatment of talipes equinovarus c. Newly diagnosed metatarsus adductus deformity

4. Considerations: (see section Pediatrics) a. Age of patientb. Osseous developmentc. Severity of deformityd. Presence of concomitant deformities e. Extent of malfunction and disability

5. Soft Tissue Surgery: (current procedures will be discussed in detail) a. Heyman, Herndon, and Strong:i. Indications: for flexible met. adductus which is reducible on manipulation (stress x-ray) usually children less than 5 years old deformity present at Lisfranc's joint, without significant bowing present in

the proximal portion of the metatarsal bones themselves ii. Procedure: 2 or 3 longitudinal dorsal incisions or transverse incision release of the dorsal, interossei, and plantar ligaments of the

tarsometatarsal joints and intermetatarsal joints preserve the plantar-lateral ligaments, especially 5th metatarsocuboid

articulation and the peroneus brevis tendon manipulate the foot into abduction K-wire fixation of the first met-cuneiform joint and 5th met-cuboid joint release of the naviculocuneiform and intercuneiform joints is rarely

needed consider abductor hallucis release or tenotomy in conjunction with HH&S iii. Precautions: avoid damage to the 1st metatarsal epiphyseal growth plate (do not

confuse this with the met-cuneiform joint) be careful not to introduce iatrogenic dorsal dislocations at the met-

cuneiform jointsiv. Postop care: cast for 6-12 weeks

NOTE* Not always accurate as the lesser tarsal bones in the neonate are not measurable as they are radiographically "silent", and in many cases the T-C relationship is abnormal. Therefore It is best to use the calcaneal second metatarsal angle (normal parameters pending)

manipulate the foot and recast every 3-4 weeks depending upon the severity

monitor the foot carefully for the development of a flatfoot deformityv. Complications: dorsal dislocation degenerative arthritis damage to the growth plates

b. Thompson procedure (modified):i. Indications: congenital hallux varus primarily flexible met. adductus secondarily hyperactivity of the abductor hallucis ms.ii. Procedure: medial longitudinal 1st MTPJ skin incision approach dissection to level of deep fascia over the abductor hallucis muscle transection of the abductor hallucis tendon with resection of a segment of

the tendon and portion of the distal muscle consider lesser MTPJ release medially if lesser digits are also adducted release of the medial head of the flexor hallucis brevis if adduction of the

hallux is still presentiii. Precautions: do not reduce varus of the hallux without ensuring correction of any

adduction deformity of the first metatarsal place the medial incision over" the 1st MTPJ strategically; if too superior or

inferior, may damage the medial neurovascular bundle avoid the procedure as a primary mode of correction for met. adductus

unless clinical findings and x-rays strongly support hyperactivity of the abductor hallucis as the primary etiology

iv. Postoperative care: weightbearing in a surgical shoe for 3-6 weeks splinting of the hallux and the first rayv. Complications: hallux abductovalgus hallux hammertoe (hallux malleus)

c. Johnson osteochondrotomy: cartilaginous procedure i. Indications: met. adductus deformity in children between the ages of 5-8 years (can be

younger)ii. Procedure: 3 dorsolongitudinal incisions closing abductory base wedge osteotomy of the 1st metatarsal wedge resection of cartilage and bone from the bases of the lesser

metatarsals, distal to the proximal articular surface (base is lateral with the apex medial)

fixation of the osteotomies with stainless steel wire, K-wires, or staples iii. Precautions:

avoid damage to the epiphyseal growth plate of the 1st metatarsal overcorrection/undercorrection of individual ray segments iv. Postoperative care: non-weightbearing with cast immobilization for 6-8 weeks serial x-rays to assess healing

6. Osseous Surgery:a. Modified Berman-Gartland procedure:i. Indications: met. adductus in the child older than 6-8 years residual deformity following treatment of talipes equinovarus ii. Procedure: 3 dorsolongitudinal incisions transverse or oblique-type closing abductory wedge osteotomy of the 1st

metatarsal similar type of osteotomies of the lesser metatarsals with the cortical

hinge medially fixation of osteotomies with SS wire, K -wires, staples, AO screws or

combinationsiii. Precautions: avoid damage to growth plates of 1st metatarsal meticulous subperiosteal dissection is critical to avoid heavy callus

formation and undesirable synostosis between adjacent metatarsals preservation of the medial cortical hinge is important to insure stability careful planning to avoid over/undercorrectioniv. Postoperative care: non-weightbearing cast immobilization 6-8 weeks convert the cast to posterior splint and start PT orthotics when patient resumes weightbearing serial x-rays to assess bone position and healing at 3 weeks , 6 weeks, 12

weeks, 24 weeks and 1 yearv. Complications: over/undercorrection delayed union/nonunion/pseudoarthrosis fracture of f cortical hinge damage to growth plate elevatus of metatarsals iatrogenically induced flatfoot deformity

b. Lepird procedure:i. Indications: met. adductus in the child older than 6-8 years residual talipes equinovarus deformityii. Procedure: 3 dorsolongitudinal incisions oblique closing-abductory wedge osteotomy (Juvara type) of the 1st

metatarsal with AO/ASIF screw fixation rotational osteotomy of each lesser metatarsal with AO/ASIF screw fixation

(2.7 mm cortical used mostly) perpendicular to the plane of the osteotomy an oblique closing wedge osteotomy may be used on the 5th metatarsal in

place of the rotational type (if preferred) rotational osteotomies are performed from dorsal-distal to plantar

proximal with temporary preservation of the cortical hinge (facilitates fixation). The osteotomy is approximately 45° from the weightbearing surface. The precise angle will depend on the declination of the metatarsal segment. As the declination of the metatarsal increases, the osteotomy will be more parallel to the weightbearing surface of the foot

area of the cortical hinge preserved is most commonly proximal/plantar the screws are then removed and the osteotomy is completed the screws are reinserted, the distal fragments are rotated laterally, and

the screws are tightened the alignment of the foot is assessed; if realignment is necessary the screw(s) can be loosened and the bone adjustediii. Postoperative care: same as Berman-Gartlandiv. Complications: same as Berman-Gartland if the osteotomy is performed too vertically the rotation of the osteotomy will be around the longitudinal axis of the metatarsal bone

itself, resulting in inversion/eversion of the bone itself v. Advantages: this procedure is amenable to rigid internal fixation and primary bone healing

over/undercorrection can be corrected during surgery biplanar correction can be achieved eliminates pin tract infections

7. Ancillary Procedures: a. Equinus Deformity: i. TALii. Gastrocnemius recessionb. Flatfoot Deformity:i. STJ arthroereisisii. Evans calcaneal osteotomyiii. Modified Young's tenosuspension/ Modified Kidner procedurearthrodesis/ N-C arthrodesis

Freiberg's DiseaseAlso known as osteochondrosis of the metatarsal head or avascular (aseptic) necrosis of the bone, most commonly affects the 2nd metatarsal 1. Etiology:a. Trauma (or trauma followed by fracture)b. Ischemiac. Prominent plantar metatarsal head with excessive loading with a compromise to the circulation to the subchondral boned. Often appears after age 13, affecting women 3 times more frequently than men

2. Signs and symptoms:a. Pain in the MPJ (usually dorsally), either sharp, dull, or aching In characterb. Edema with increased activityc. Limitation of motion of the involved digit and MPJ d. Palpable irregularities may be present dorsally e. Distal distraction of the toe will cause painf. Adjacent MPJ hyperkeratoses may be present as the Involved metatarsal bears less weight

3. X-ray evaluation:a. The initial findings include a joint space widening 3-6 weeks after the onset of symptomsb. This is followed by increased density of subchondral bonec. As the disease progresses, a zone of rarefaction develops surrounded by a sclerotic rimd. With time, the epiphyseal bone weakens and collapses with the formation of spicules and loose bodiese. Flattening of metatarsal head with osteophytic lipping f. Joint narrowingg. Peripheral soft tissue swellingh. Bone margins are sclerotic

4. Treatment:a. Directed toward preventing further damage and displacement of the MPJ (casting and cortisone shots followed by orthoses)) b. Later stages:i. Implant arthroplasty: If symptoms are due to joint arthritisii. Metatarsal head remodeling (must preserve the alignment of the toeuse splint 3 months postoperatively)iii. Bone grafts (Smillie): To restore the contour of the metatarsal head by inserting a cancellous graft (good for stage 1-3)iv. Rotational osteotomies (Gauthier and Elbaz): Rotates the lower aspect of the metatarsal head dorsally after a section of damaged cartilage has been excised. This allows the plantar cartilage to articulate with the proximal phalanx

NOTE* Dr. Freiberg's only surgical treatment involved removing the loose bodies

5. Classification (by Smillie into 5 stages):

a. Stage 1: Fissure fractureb. Stage 2: Absorption of bone. Central aspect of bone is sinking into the metatarsal headc. Stage 3: Further. progression with projections remaining on either side of the metatarsal head. The plantar articular cartilage remains intact d. Stage 4: Fractures and loose bodies may occur. Plantar cartilage no longer intacte. Stage 5: Flattening of the metatarsal head.

Tailor's Bunion 1. Etiology:a. Any uncompensated varus position of the forefoot or rearfoot in a fully pronated footb. A congenital plantarflexed 5th ray deformityc. A congenital dorsiflexed 5th ray deformity

d. Idiopathice. Lateral deviation or wide 5th metatatarsal head f. Combined influences

2. Clinical findings:a. Prominence over the 5th metatarsal head with painb. Hyperkeratosis and erythema over the 5th metatarsal head area c. 5th toe assumes a varus or adducto varus attitude

3.

Radiological findings:-6 types according to the findingsa. Rotation of the lateral plantar tubercle into a lateral positionb. Increased IM angle (normal 6.47°): People with tailor's bunion have an IM of 8.71 or greater (Fallat and Buckholz)c. Increased lateral deviation angle (normal 2.64°) People with tailor's bunion have a lateral deviation angle of 8.05° (Fallat and Buckholz) d. A large "dumbell-shaped" 5th metatarsal head e. Arthritic changes resulting in exostosis formation at the 5th MPJf. Any combination of the above conditions, the 1st three being most common

4. Surgical management:1. Hohmann osteotomy: Single transverse osteotomy at the level of the metatarsal neck with medial displacement of the capitol fragment b. Oblique osteotomy from distal lateral to proximal medial with displacement of the capital fragment proximally and medially (reverse Wilson procedure)c. Modified Mitchell: Step down osteotomyd. Austin type osteotomy: 2 mm of medial transpositione. Mercado osteotomy: Medially based closing wedge osteotomy at the metatarsal neckf. Yancy osteotomy: Midshaft medially based closing wedge osteotomyg. Gerbert et al osteotomy: Proximal diaphyseal closing wedge osteotomy h. Buchbinder osteotomy: DRATOi. McKeever: Partial metatarsal head resectionj. Kelikian: Partial metatarsal head resection with syndactylization of the 4th and 5th toesk. Distal oblique osteotomy with intramedullary K-wire fixation

NOTE* Must determine if a splayfoot deformity is present. Evaluate on weight-bearing and x-ray. Radiographically, splayfoot deformity is characterized by an IM angle between the 1st and 2nd metatarsal of greater than 12° and between the 4th and 5th metatarsals of greater than 8°. In association with varus of the 1st metatarsal, the slant of the distal articular surface of the medial cuneiform is more than 105°

SplayfootAs this deformity consists of high IM angles for the 1 st and 2nd , and 4th and 5th, surgical repair is focused on reducing the IM angles. This is accomplished via a closing base wedge osteotomy of the 1 st metatarsal with AO fixation, and distal oblique osteotomy of the 5th metatarsal with K-wire fixation.

Brachymetatarsia (Brachymetapody)1. Etiology:a. Congenital: Premature idiopathic closure of the distal epiphyseal growth plate

NOTE* Excessive 5th metatarsal head resection results in laxity of the internal cubic content of the joint leading to further varus or adducto varus malalignment of the 5th toe, and more retrograde pressure on the 5th metatarsal head

b.

Traumatic c. Infectious

2. Clinical presentation:a. Symptoms usually appear in adolescence when full growth discrepancy is most apparentb. In the younger patient the only complaint will be the appearance of a shortened or "floating" toec. The adjacent toes underlap the involved toed. Calluses under the adjacent metatarsal heads with metatarsalgiae. The amount of associated disability typically depends upon the amount of weight that Is transferred to the adjacent metatarsal heads f. A deep sulcus is present underneath the short metatarsal

3. Radiological findings:a. Short, underdeveloped metatarsal with deficient bone content b. Osteoporosis of the metatarsal head

4. Operative planning:a. Consider the amount of length needed to restore the normal metatarsal parabolab. Must consider whether to lengthen and plantarflex the involved metatarsal or shorten and dorsiflex the adjacent metatarsals c. Soft tissue mobility and neurovascular status of the involved ray d. Use of a bone graft either autogenous or allogeneic

5. Procedure:a. Bone lengthening procedure (frontal plane "Z" osteotomy) b. Insertion of corticocancellous bone graft c. Extensor tenotomyd. " V" to "Y" skin plastye. BK NWB cast until osseous healing

6. Complications:a. Risk of neurovascular compromise b. Non-unionc. Absorption or collapse of the graft

NOTE* The congenital pattern has also been associated with neonatal hyperthyroidism, pseudohypoparathyroidism, pseudo-pseudohypoparathyroidism, malignancy, Down's syndrome, Albright's syndrome, myositis ossificans, Turner's syndrome, sickle-cell anemia, Still's disease, and enchondromatosis

NOTE* The iatrogenic and traumatically induced types of brachymetatarsia are usually more acute and severe in their presentation

d. Painful pseudoarthrosise. Painful limitation of motion at the joint

Skewfoot1. Description: A metatarsus adductus forefoot-type with a pathological rearfoot valgus component

2. Etiology:a. After serial casting for metatarsus adductus in which the rearfoot was in a pronated positionb. Untreated metatarsus adductus which has compensated by excessive subtalar joint pronationc. Congenital metatarsus adductus with associated calcaneovalgus

3. Clinical evaluation:a. The metatarsals are angulated mediallyb. The base of the 5th metatarsal is prominentc. A large space is noted between the hallux and 2nd toe d. A metatarsus varus may be presente. The digits are abducted in stancef. Talar bulging (ptosis) on weight-bearing with low medial archg. Abducted midfoot position with internal rotation of the malleoli h. Rearfoot equinus may be present

4. Types:a. Simple skewfoot: An adducted forefoot with an abnormally pronated rearfootb. Complex skewfoot: An adducted forefoot, abducted midfoot, and abnormally pronated rearfoot

5. Radiological evaluation:a. Increased metatarsus adductus angle (MA angle greater than 21 °) b. Increased cuboid abduction angle (greater than 5°)

6. Indications for surgery:a. Too old for correction by conservative meansb. Deformity is increasing despite conservative treatmentc. Deformity is obviously not manageable by conservative means d. Deformity is beginning to cause secondary deformities e. Patient is experiencing painful compensatory symptomsf. Patient is accommodating to life style because of related symptoms g. Increased difficulty with standard shoegear

7. Surgical repair: As this Is a complex deformity, multiple procedures must be employed as necessarya. Equinus correction: Gastrocnemius recession or TAL as indicatedb. Pes valgoplanus correction: Evans opening calcaneal osteotomy and medial arch tenosuspension. The Evans osteotomy lengthens the lateral column and therefore, realigns the midtarsal joint

c. Metatarsus adductus correction: Modified Berman-Gartland or Lepird d. Subtalar joint instability and bony adaptation: STJ arthrodesis

NOTE* This procedure can unmask a previously unappreciated metatarsus adductus