Pertinent Pearls On Fifth Metatarsal Osteotomies

Start Page: 44
Jane Pontious, DPM, FACFAS, and Corine Creech, DPM

Navigating Proximal Osteotomies

Proximal osteotomies. These osteotomies will allow for the greatest degree of correction. However, they are technically difficult and one must select them only in appropriate scenarios. Historically, surgeons considered these procedures as less favorable options due to the delicate blood supply to the base of the fifth metatarsal as well as the instability of the osteotomies themselves.1,15 The deformities well suited for this type of procedure include those with a significantly increased fourth-fifth intermetatarsal angle and splay foot deformities.9,10 Gerbert’s indications included a non-arthritic joint in the presence of a deformity that involved the entire metatarsal.16

   When faced with a deformity that is appropriate for treatment with a proximal osteotomy, the senior author prefers a reverse closing base wedge osteotomy. Several things to be cautious of include meticulous dissection to avoid the lateral dorsal cutaneous nerve and avoid violating the joint between the fourth and fifth metatarsal bases while making the cut itself.1,9,10,11 Proper fixation and stabilization is absolutely critical as these osteotomies are more prone for delayed/non-union. Some authors have recommended placing this osteotomy in the proximal portion of the diaphysis in order to decrease the risk of delayed or non-union.17

   The postoperative course will need to involve cast immobilization, analogous to that of a closing base wedge osteotomy one would use to correct a severe hallux valgus deformity.9,10

What You Should Know About Ancillary Procedures

It is important to evaluate the fifth toe in the presence of a tailor’s bunion. Just as a deviated hallux applies a retrograde force onto the first metatarsal, thus increasing the intermetatarsal angle in a hallux valgus deformity, an adductovarus fifth toe will have the same effect on a fifth metatarsal. This obviates the need for correction.1,9 You must consider, however, that this can increase the amount of shortening of the fifth ray when it is combined with a distal or proximal osteotomy.

How To Remediate Complications

Complications of tailor’s bunion correction are similar to many other surgeries. These complications include a painful/unsightly scar, neuritis/nerve entrapment, infection and transfer lesion/metatarsalgia.9,10 We advocate fixation of these osteotomies as the literature has shown that fixation will allow for increased rates of healing and consolidation as well as decreased rates of non-union/delayed union.17 In addition, researchers have shown that fixation decreases the amount of dorsal displacement of the capital fragment, thus preventing transfer lesions and metatarsalgia.17

In Conclusion

It is important to evaluate these procedures appropriately and determine which procedure will work best in your hands for each type of deformity. Re-familiarize yourself with the anatomy of the fifth ray and plan accordingly to avoid transection of any vital structures. Be open and honest with your patients about your decision making process and what they can reasonably expect postoperatively.

   Dr. Pontious is a Professor and Chair of the Department of Surgery at the Temple University School of Podiatric Medicine in Philadelphia.

   Dr. Creech is a second-year resident at Temple University Hospital in Philadelphia.

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