Why The Panmetatarsal Head Resection Can Be A Useful ‘Last-Resort’ Procedure
The panmetatarsal head resection and triple arthrodesis are the ultimate reconstructive surgeries for the hindfoot and forefoot respectively. Often, we think of the panmetatarsal head resection only for patients with rheumatoid arthritis. I have found the procedure to be very useful in many other scenarios.
We tend to believe that if one needs a triple arthrodesis or a panmetatarsal head resection, then we have failed in some fashion to save the patient's foot from doom. The bottom line is that a well-performed triple arthrodesis and panmetatarsal head resection provide deformity resolution and stability to the foot.
I call these procedures “last-resort surgeries.” However, that does not mean one needs to perform other reconstructive surgeries that would have a high potential for failure just to avoid a last-resort surgery. A definitive reconstruction surgery such as a panmetatarsal head resection may be the first line of treatment, even though it is a last-resort surgery.
We have all been trained with the same type of decision-making logic where A+B=C. For example, it is a knee-jerk response to associate the panmetatarsal head resection with the patient with rheumatoid arthritis who has severe derangement of the digits. One may also consider a panmetatarsal head resection in common scenarios that include:
• severe iatrogenic deformities of the forefoot;
• severe metatarsus adductus deformity with laterally windswept toes (in the older patient); and
• in patients with chronic metatarsalgia who have failed surgical treatments.
In the patient with rheumatoid arthritis, I have found that a plantar approach for removal of the lesser metatarsal heads is ideal. Some of the benefits include:
• less dissection (which leads to less vascular compromise to the toes);
• relocation of the anterior displaced fat pad; and
• the ability to remove associated bursae and/or ulcerative skin under the metatarsal head(s).
I do not find that there is any wound healing difficulty with the plantar incision. The skin heals very well with very little scarring.
There is always the debatable question of what to do with the first metatarsophalangeal joint when doing a panmetatarsal head resection. My preference is to do an arthrodesis of the joint. I feel this adds stability of the medial column and prevents future deformity of the great toe position. I tend to use minimal fixation for these patients. I typically use two compression staples at 90 degrees to one another (one dorsal and one medial for maximum stability). I may also use a combination of staple(s) and K-wire(s).
In summary, we want to provide our patients with surgical care that minimizes repeat surgeries for obvious reasons. It is human nature to offer and/or try something other than a last-resort surgery. We have all been guilty of trying a heroic surgical attempt so the patient does not have to succumb to our own psychological feeling of failure or salvage operation. Certainly, you and your patient have to make the decision. In the case of a severely deformed foot that is a source of chronic pain, patients want something done no matter what it takes to be able to wear a shoe and function again without pain.
Therefore, consider a definitive, time-tested and predictable surgery in these cases. Let us face it. None of us wants to have a triple arthrodesis or panmetatarsal head resection, but it certainly has its role in the reconstruction of severely arthritic, unstable and deformed feet.