SLR - January 2018 - Peter A. Ferrante

Anatomical Reconstruction of the Fourth Brachymetatarsia with One-Stage Iliac Bone and Cartilage Cap Grafting

Reference: Woo SH, Bang CY, Ahn HC, Kim SJ, Choi JY. Anatomical Reconstruction of the Fourth Brachymetatarsia with One-Stage Iliac Bone and Cartilage Cap Grafting. Journal of Plastic, Reconstructive & Aesthetic Surgery. 2017 May 31;70(5):666–72.

Scientific Literature Review

Reviewed By: Peter A. Ferrante, DPM                                                                                              
Residency Program: NYU Langone Hospital Systems, Brooklyn, NY

Podiatric Relevance: Brachymetatarsia is a congenital deformity in which the patient will seek help due to cosmetics when barefoot and wearing open-toed shoes. A popular surgical solution is distraction osteogenesis. The authors argue that a one-step lengthening of the metatarsal with iliac crest grafting at the epiphyseal region to anatomically realign the articular cartilage can become an equal standard of care for brachymetatarsia and can solve some of the complications with distraction osteogenesis, including joint stiffness.

Methods: The surgical procedure involves an osteotomy at the epiphysis of the fourth metatarsal, allowing the surgeon to realign the cartilage intraoperatively on the graft with k-wire fixation. This study is a retrospective review of 56 feet in 41 patients who underwent a one-stage autogenous iliac bone grafting between 2008 and 2015. The primary objectives of the procedures were cosmetic, not functional. Cosmetic satisfaction was measured by overall configuration of the foot, operative scar, donor site morbidity and comparative symmetry of both feet. In addition, radiographs were used to measure metatarsal lengths, including gains and percentages, healing time and status of the graft union. Cartilage cap and bone graft viability were checked on MRI.

Results: Of the 56 metatarsals, the length was noted to increase by 39 percent on average. No intraoperative complications were noted. One instance of nonunion occurred at the proximal graft and metatarsal bone, but the patient was asymptomatic and refused a second procedure. All patients were able to flex their toes satisfactorily, but 13 patients complained of limited dorsiflexion of the fourth toe. No major donor site complications occurred. Of the 18 patients who agreed to undergo an MRI, 15 of them had no or minimal articular irregularity at the fourth metatarsophalangeal joint. The three patients with moderate irregularity were asymptomatic. All patients stated that they would undergo the procedure again if needed.

Conclusion: The authors of the study concluded that their surgical technique provided good cosmetic results with less complication. Postoperative management was standard and did not require additional patient cooperation involving external fixation, as in distraction osteogenesis. However, due to the limited number of patients who underwent an MRI, the study is limited in its evaluation of cartilage cap viability. The toe dorsiflexion issues may be due to the fact that the flexor tendons went untouched, while the extensor tendons were lengthened intraoperatively. While there certainly are complications involved with distraction osteogenesis, immediate metatarsal lengthening with bone graft also has its fair share of complications. Donor site morbidity and graft adherence are a few, but one of the more immediate complications can be the disruption of blood flow to the digit due to sudden lengthening. Both surgical procedures come with their fair share of concerns, so it is important for podiatric physicians to choose their patient wisely to ensure the best outcome for either procedure. While the results may claim that the described procedure is effective for cosmetics, further testing is needed before it can be stated that one-step lengthening can effectively decrease the chance of MTP joint stiffness and malalignment.

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