SLR - August 2017 - Amy A. Wong

Mini-Invasive Floating Metatarsal Osteotomy for Resistant or Recurrent Neuropathic Plantar Metatarsal Head Ulcers

Reference: Tamir E, Finestone A, Avisar E, Agar G. Mini-Invasive Floating Metatarsal Osteotomy for Resistant or Recurrent Neuropathic Plantar Metatarsal Head Ulcers. J Orthop Surg Res. 2016 Jul 11; 78.

Reviewed By: Amy A. Wong, DPM 
Residency Program: Boston University Medical Center, Boston, MA

Podiatric Relevance: Diabetes affects 30 million people in the United States and more than 415 million people worldwide. Sixty to seventy percent of those with diabetes will develop peripheral neuropathy or lose sensation in their feet. The annual incidence of ulcers in patients with diabetes mellitus is about two percent, and ulcers have been implicated as a causative factor in up to 84 percent of diabetic foot amputations. Offloading a diabetic foot ulcer is important to healing. There are many approaches in managing a diabetic foot ulcer from conservative measures to amputations. Surgical interventions are taken into consideration after all conservative measures have failed, and there are procedures that take an approach to minimize complications. The authors of this article were attempting to assess the effectiveness and postoperative results of the mini-invasive floating metatarsal osteotomy.

Methods: A retrospective chart review of 17 patients living with diabetes who underwent an osteotomy between 2013 and 2014 after all conservative measures failed. Twenty osteotomies were performed on patients with University of Texas stage 1A ulcer and by one surgeon. Factors taken into consideration were diagnosis of DM, cause of neuropathy, duration and location of current ulcer, location of osteotomy, ulcer status six weeks after surgery and complications, both major and minor. Major complications were those infections requiring antibiotics and minor complications included recurrence, transfer lesions and nonunion.

Results: Twenty osteotomies performed on 17 patients, which were all females except for one male. Mean age was 58, and mean duration of DM was 17 years. Mean age of the ulcers were 19 months. Of 18 primary osteotomies, 15 procedures included one metatarsal, and three included two metatarsals.  

All surgical wounds, except one case, healed within one week. With that one case, postoperative infection with osteomyelitis developed at the osteotomy site; however, the patient was treated with bone debridement and antibiotics.

After 17/20 operations, the ulcer completely resolved after six weeks and no recurrence with a mean follow-up of 11.5 months. The other three patients showed improvement but did not heal. In six cases, nonunion occurred—three after osteotomy of the neck and three after osteotomy of the shaft.  

Two patients developed a transfer lesion. One developed a lesion to the fourth metatarsal head five months after osteotomy was performed on the second metatarsal neck. The other lesion was noted below the second metatarsal head 10 months after osteotomy of the third metatarsal neck.

Conclusion: The authors concluded that although some complications were encountered, overall, this mini-invasive floating metatarsal osteotomy is a safe and effective curative and prophylactic procedure for grade 1 ulcers over other open osteotomies with hardware placement with higher rate of complications, such as infection and wound dehiscence. Nonunions, transfer lesions and reulceration were the major complications; however, this procedure seems to be an option to recommend to patients, especially those who are noncompliant in non-weightbearing status.  

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