Can Minimal Incision Metatarsal Neck Osteotomies Have An Impact For Recalcitrant Neuropathic Ulcerations?

In our high-risk patients with diabetic neuropathy, we exhaust all conservative treatment options to heal and prevent the recurrence of wounds. Despite our best efforts, some diabetic ulcers fail to heal. This creates an increased risk of infection and patients may ultimately progress to amputation.

In instances in which forefoot ulcerations become recalcitrant, surgery is often unavoidable. A minimal incision dorsal to plantar osteotomy of the metatarsal can significantly decrease plantar pressures and hasten wound healing. These osteotomies effectively allow realignment of the metatarsal to a more dorsal position, decreasing overall plantar pressure.¹ They also allow weightbearing forces to be redistributed more evenly throughout the forefoot.² The definition of a minimally invasive surgery is a surgery performed through the smallest incision necessary to complete the procedure.³ The incision is between 1 to 2 cm in length, allowing direct visualization of the osseous or soft tissue structures one is addressing.³

Minimally invasive surgery techniques have several proposed benefits, including shorter surgical times and decreased risk of complications.³ In the patient with diabetes, this technique allows for a shorter recovery period and decreased risk of infection from surgery. 

Unfortunately, the literature on this technique is sparse. The primary focus of metatarsal osteotomies has been the treatment of painful calluses, intractable plantar keratoses and metatarsalgia.² Leventen and Pearson studied the distal metatarsal osteotomy for the treatment of intractable plantar keratoses.⁴ They performed a V-shaped trough type osteotomy without fixation in the middle third of the metatarsal shaft in 21 feet. The authors reported an overall success rate of 86 percent with 15 cases having good or excellent results. They considered three cases to be failures. In two cases, there was no improvement of the preexisting callus and the remaining failure was secondary to painful dorsiflexion non-union. They concluded that distal metatarsal neck osteotomies can be successful in the treatment of painful intractable plantar keratoses without fixation.

Another study by Fleischli and colleagues reports the results of performing a dorsiflexion metatarsal osteotomy as a salvage procedure in patients with diabetic neuropathic forefoot ulcers.² Twenty patients with diabetes had 22 dorsiflexion metatarsal osteotomies. The authors performed a basilar closing wedge osteotomy through a dorsal approach. They noted complete ulcer healing within 40 days in 21 of 22 cases. There were no cases of ulcer recurrence but transfer lesions developed in two cases. Complications occurred in 15 cases with the primary problems being acute Charcot (32 percent) and infection (14 percent). Ultimately, the authors concluded that dorsiflexion metatarsal osteotomy is reliable as a salvage procedure for the treatment of recalcitrant neuropathic forefoot ulcers although the complication rate is high.

It is important to reiterate that the dorsal to plantar metatarsal neck osteotomy is a limb salvage procedure to avoid future amputation and surgeons perform it after months of failed conservative treatment. Patient selection, as with all surgeries, is of the utmost importance. Practitioners should be aware of the proposed risks of this procedure, primarily the risks of transfer lesions and Charcot arthropathy in this population.

A Guide To The Surgical Technique

The surgery begins with the patient on the operating room table in the supine position. One may or may not use an ankle tourniquet. Avoid the use of hemostasis in patients with known arterial disease. Following a local block to the area with or without intravenous sedation, make an approximately 1 or 1.5 cm linear incision through the skin of the dorsal forefoot directly over the metatarsal to be elevated. One may palpate the metatarsal from the plantar aspect, allowing visualization of the metatarsal dorsally prior to skin incision. There is often an open wound or callus directly beneath the metatarsal head.

Following the initial skin incision, perform blunt dissection using hemostats through the subcutaneous and deep tissues down to the level of the metatarsal. The metatarsal head and the neck may be visible at this time. Perform sharp dissection of any remaining soft tissue attachments to the metatarsal neck if necessary. Palpate the plantar aspect of the metatarsal again to ensure appropriate dissection of the proper metatarsal. Then use a sagittal saw to create a dorsal to plantar cut through the metatarsal neck. Apply pressure to the plantar aspect of the metatarsal to allow translation of the capital fragment dorsally. We do not routinely use fixation in our patients with diabetes. This allows the capital fragment to realign itself and “seek its own level.”⁵

Irrigate the surgical site with normal sterile saline and perform wound closure. Apply a sterile dressing and place the patient in a surgical shoe. Patients may ambulate on this foot immediately with transition back to a normal or diabetic shoe following the removal of skin sutures.

References

1. Roukis TS, Schade VL. Minimum-incision metatarsal osteotomies. Clin Podiatr Med Surg. 2008; 25(4):587-607.
2. Fleischli JE, Anderson RB, Davis WH. Dorsiflexion metatarsal osteotomy for treatment of recalcitrant diabetic neuropathic ulcers. Foot Ankle Int. 1999; 20(2):80-85.
3. Roukis TS. Percutaneous and minimum incision metatarsal osteotomies: a systematic review. J Foot Ankle Surg. 2009; 48(3):380-387.
4. Leventen EO, Pearson SW. Distal metatarsal osteotomy for intractable plantar keratoses. Foot Ankle Int. 1990; 10(5):247-251.
5. Roukis TS. Central metatarsal head-neck osteotomies: indications and operative techniques. Clin Podiatr Med Surg. 2005; 22(2):197-222.

Additional References

1. Giannini S, Faldini C, Vannini F, et al. The minimally invasive osteotomy “SERI” (simple, effective, rapid, inexpensive) for correction of bunionette deformity. Foot Ankle Int. 2008; 29(3):282-286.
2. Frykberg RJ, Bevilacqua NJ, Habershaw G. Surgical off-loading of the diabetic foot. J Vasc Surg. 2010; 52(3):44S-58S.
3. Espinosa N, Maceira E, Myerson MS. Current concept review: metatarsalgia. Foot Ankle Int. 2008; 29(8):871-879.
4. Feibel JB, Tisdel CL, Donley BG. Lesser metatarsal osteotomies: A biomechanical approach to metatarsalgia. Foot Ankle Clin. 2001; 6(3):473-489.