Key Insights On Intractable Plantar Keratoses

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Author(s): 
William Fishco, DPM, FACFAS

Other Keys To Appropriate Procedure Selection

When shortening metatarsals, I typically prefer a distal neck osteotomy. Generally, I will do a Weil type osteotomy. If I need to shorten the metatarsal more than 3 to 4 mm, then I will typically do a step down Z osteotomy.

   To raise metatarsals, I typically do a distal V osteotomy or “tilt up” procedure. If I need significant dorsal elevation, I will do a dorsiflexory base wedge osteotomy.

   Typically, I reserve condylectomies and isolated fifth metatarsal head resections for geriatric patients or for patients who cannot mentally or physically handle reconstructive surgery.

   Iatrogenic deformities of the forefoot tend to be the most challenging for surgical reconstruction. Intractable plantar keratoses are common after failed bunion surgeries and with prior lesser metatarsal osteotomies. Excessive shortening of the first metatarsal and/or dorsiflexion of the capital fragment following bunion surgery leads to lesser metatarsal overload. This often leads to intractable plantar keratosis under the second and sometimes third metatarsal heads.

   Surgical management generally includes lengthening and plantarflexion of the first metatarsal as well as shortening the affected metatarsal in the central rays. A sagittal Z osteotomy works well for small amounts of lengthening and plantarflexion of the first metatarsal. In scenarios in which a significant amount of lengthening is necessary, bone grafting and/or callus distraction may be indicated.

   Don’t forget about the pan metatarsal head resection. This is a time-tested method for resolving chronic metatarsalgia and intractable plantar keratoses. This procedure should always be in the back of your mind as a salvage procedure for severe metatarsal derangements, revision of failed surgery or in the older patient with less physical demand.

   It is easy to fall into the mental mindset that a patient has a callus because of a “dropped metatarsal.” It is a disservice to your patient simply to recommend a condylectomy or metatarsal osteotomy that may be doomed to failure without addressing other biomechanical causes. Always consider multiple reasons for the cause of the intractable plantar keratosis.

In Conclusion

Rather than just assuming the intractable plantar keratosis is due to a long metatarsal or plantarflexed metatarsal, physicians should evaluate the condition globally with respect to arch type, concomitant deformities and biomechanical influences. Don’t forget to have the patient get out of the treatment chair and walk for you to assess his or her gait.

   Hopefully, a treatment that addresses functional faults and structural deformities will lead to good outcomes for your patients with resolution of pain and accompanying intractable plantar keratoses.

   Dr. Fishco is board-certified in foot surgery and reconstructive rearfoot and ankle surgery by the American Board of Podiatric Surgery. He is in private practice in Phoenix. He is also a faculty member of the Podiatry Institute.

   Dr. Fishco pens a monthly blog for Podiatry Today. For more info, visit http://www.podiatrytoday.com/blogs/william-fishco-dpm-facfas .

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Ian Reillysays: April 4, 2012 at 4:53 am

Nice review Dr. Fishco. I have come to all the same conclusions and have a similar toolbox of procedures. The one thing I do with a Weil now is take a wedge of bone out to shorten and slightly elevate. There is some evidence that a pure Weil plantarflexes the capital fragment somewhat. In the U.K., we call this a Schweil – a Weil-Schwartz combo!

Best wishes

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William D. FIshco, DPMsays: April 5, 2012 at 11:22 pm

I do take a dorsal wedge as well if I am going to shorten the metatarsal more than 3 mm.

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