Pertinent Pearls On Fifth Metatarsal Osteotomies

Jane Pontious, DPM, FACFAS, and Corine Creech, DPM

   The surgeon would optimally place a linear or curvilinear incision roughly 3 cm in length, beginning from the midshaft of the fifth metatarsal and extending distally.9-11 Typically, a dorsolateral incision is preferred. This will ensure adequate exposure to all necessary structures.9-11 Take care around this area due to the tributaries of the lateral marginal vein. Layered dissection will allow for visualization of these structures and one should appropriately ligate and cauterize them as needed.

   Additional structures to note in this area include the neurovascular bundle. If it is visible, one can safely retract this out of the surgical field. Identifying and safely retracting vital structures away from the surgical site will allow for the use of a longitudinal incision through the deep fascia and the periosteum. The senior author prefers to use a Freer elevator to assist with subperiosteal dissection, maintaining that it is generally easier to begin this dissection proximally as the periosteum adheres less to the bone at this level. It is important to resect enough periosteum to accommodate your osteotomy but do not be overly aggressive with this dissection as it can be detrimental to healing.

Weighing The Pros And Cons Of Lateral Exostectomies And Distal Metatarsal Osteotomies

Lateral exostectomy. The lateral exostectomy is a technically simple procedure that offers reproducible results. It continues to be in use today as both an individual and adjunct procedure. Things to note with this procedure include minimal soft tissue dissection and resection. When using the lateral exostectomy as a sole procedure, it is not necessary to carry dissection into the joint capsule. This will lead to less postoperative fibrosis. It is also vital to remove only one-fourth to one-third of the diameter of the bone.3,4,10 This will prevent destructive changes to the joint long term as well as postoperative dislocation. This procedure also has the advantage of allowing the patient to bear weight on the foot immediately postoperatively in a surgical shoe.9-11

   Distal metatarsal osteotomies. Distal metatarsal osteotomies occur at the metaphyseal-diaphyseal junction of the fifth metatarsal.9-12 Surgeons have traditionally noted that these osteotomies are appropriate procedures for those deformities that are moderate in severity yet require more correction than a lateral exostectomy can yield.9,10 The senior author has found that distal osteotomies are incredibly versatile procedures and are capable of correcting a majority of the deformities podiatric surgeons encounter.

   Distal metatarsal osteotomies are wonderfully reproducible and predictable procedures for several reasons, the first being that placement of these osteotomies is in a location that is predominately cancellous bone.9-11 Due to the increased vascularity that this affords, these osteotomies are at a reduced risk for non-union, malunion or delayed union. The senior author has also found that these procedures are technically less difficult than some of the more proximal osteotomies. This allows for decreased time under anesthesia, which in turn leads to a decreased morbidity for patients. With experience and the variety of procedures that are appropriate to execute at this location, the senior author can typically find a preferable procedure.

Key Insights On Transverse And Oblique Osteotomies

Transverse osteotomy. Some of the more traditionally utilized procedures include the transverse (Hohmann), oblique (Helal) and Chevron, to name a few. The transverse osteotomy, although technically easy, may be less favorable as it is not capable of providing as much correction as some of the other osteotomies.9,10,13,14 Only consider the transverse osteotomy when the deformity requires a minimal amount of displacement.9

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