Lesser Metatarsalgia: Are Lesser Metatarsal Osteotomies Necessary?

Ramy Fahim, DPM, and Lawrence DiDomenico, DPM, FACFAS

   Additionally, since there is no surgery on the bony structures, there is no rotation, shifting, malalignment or shortening of the digits. The tendon transfer treats the underlying pathology: the dynamic deforming force of the tendon. Therefore, this eliminates the need to disturb the natural osseous structures of the three phalanges. After addressing the underlying pathology and removing the deforming forces, you can typically remove the K-wire after two weeks. Lastly, if there is a complication, one could always perform a bony procedure if necessary.

In Conclusion

There is some controversy with the treatment of lesser metatarsalgia as different schools of thought exist with variable levels of supporting evidence and success. We present an approach built on the understanding of pathomechanical factors associated with primary metatarsalgia. Addressing the equinus deformity, first ray instability and associated digital and lesser metatarsophalangeal joint instability are integral in providing a more predictable outcome.

   Lesser metatarsal osteotomies do provide viable solutions in addressing lesser metatarsalgia and various authors have demonstrated this in the literature through various case series. However, these procedures do not offer long-term predictability and often have associated complications such as floating digits and transfer metatarsalgia.

   A recent study by Peck and colleagues reviewed the outcomes of non-operative versus operative management of lesser MPJ instability.10 Operative techniques included the Weil osteotomy, lesser toe procedures and flexor to extensor tendon transfers. The authors reported no statistical difference in patient satisfaction and AOFAS scores over a mean follow-up of 55 and 70 months for operative and non-operative patients respectively. Accordingly, it is safe to deduce that while lesser metatarsal osteotomies have long-term benefits, there are also limitations that can be attributed to their inability to address the associated deforming forces.

   Traditionally, lesser metatarsalgia has been associated with anatomic variations in the structure of the metatarsal bones, specifically “fixed” plantarflexed positions. The concept has been widely accepted in foot and ankle literature without supporting evidence. As a result, procedures strictly designed to address the isolated metatarsals cannot sustain the biomechanical forces that influence the instability at the lesser MPJs.

   We need to revisit the notion of decompressing the “plantarflexed” metatarsals with more critical thought. As foot and ankle specialists, we should objectively consider how many of those lesser metatarsalgia patients have “plantarflexed” lesser rays, how are they plantarflexed relative to the other metatarsals, what caused this condition and finally, at what point during human development do those metatarsals assume the plantarflexed position?

   Overall, it is important for the foot and ankle specialist to consider the following elements for lesser metatarsalgia presentations:
• etiology of the deformity;
• contributing biomechanical factors;
• conservative and surgical procedures addressing the etiologies; and
• the predictability of those
surgical procedures

   We present an approach to re-evaluate and reconsider lesser metatarsalgia management while examining the biomechanical factors that contribute to the clinical presentation. The approach offers a predictable measure with sound clinical evidence that has seldom been challenged in the foot and ankle literature.

   Dr. Fahim is a Fellow with the Reconstructive Rearfoot and Ankle Surgical Fellowship within the Ankle and Foot Care Centers and the Kent State University College of Podiatric Medicine.

   Dr. DiDomenico is affiliated with the Forum Health/Western Reserve Care System in Youngstown, Ohio. He is the Section Chief of Podiatry at St. Elizabeth’s Hospital in Youngstown, Ohio. He is the Director of the Reconstructive Rearfoot and Ankle Surgical Fellowship within the Ankle and Foot Care Centers and the Kent State University College of Podiatric Medicine. Dr. DiDomenico is a Fellow of the American College of Foot and Ankle Surgeons.

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