What Options Exist When Complications Arise After An Osteotomy To Avoid DFU Recurrence?

Podiatric surgeons commonly perform procedures for hallux abducto valgus, and capital osteotomies of the first metatarsal are often part of this armamentarium. The technicality of these procedures is relatively straightforward, but complications can occur. These range from one to 55 percent^1,2 and include over- (varus) and under- (valgus) correction, displacement, delayed- and non-union, osteomyelitis and avascular necrosis.^3,4,5 This type of osteotomy may also accomplish “intrinsic offloading” when associated with recurrent plantar neuropathic ulcerations.

When Complications Arise From A Capital Osteotomy To Prevent DFU Recurrence

A 45-year-old patient with type 2 diabetes presented with a history of recurrent sub-first metatarsal head ulcerations over a two-year period. Previous management included total contact casting, and later accommodative orthotic care. This allowed complete healing of the ulceration. However, recurrence occurred in about eight weeks. This cyclic process of offloading and healing occurred on four separate occasions. With the last instance, we discussed correction of the hallux valgus deformity, which was the primary etiology of the ulcerations. Radiographs reflected a first intermetatarsal (IM) angle of 14 degrees and a hallux abductus angle of 28 degrees. Her HbA1c was 7.1 percent. The first metatarsal was somewhat rigidly plantarflexed, secondary to neuropathic motor loss of the intrinsic musculature about the first metatarsophalangeal joint (MPJ).

The ulceration healed again by total contact casting, and within the next week the patient underwent a double osteotomy of the first metatarsal.⁶ We used a hinge axis principle approach for the first metatarsal osteotomy to allow for dorsiflexion of the first metatarsal head and lateral displacement to correct the IM angle. At two weeks postop, the surgical wound showed signs of infection. Despite orders for non-weight-bearing on a knee scooter, the patient ambulated fully weight-bearing, as she felt no pain due to her loss of protective sensation. Radiographs indicated displacement of the first metatarsal head with hardware loosening.

Due to the displacement of the capital fragment and the potential for osteomyelitis, we performed a hardware removal and stabilized the first metatarsal head with a 0.062-inch K-wire. The dorsal cortex was comminuted, which led us to pack bone chip allograft and bone marrow aspirate the dorsal wing of the osteotomy.^7,8 We instilled vancomycin powder at the bone/capsule interface and closed the capsule.^9,10 The first metatarsal head and proximal phalanx stabilization then took place with a mini external fixator.^11-14 The recurring surgical incision site was left open, and negative pressure wound therapy allowed secondary closure.

Intraoperative bone biopsy and cultures of deep tissue and bone did not reveal infection. We kept the patient non-weight-bearing for eight weeks, at which time we removed the external fixator. Consolidation and healing of osteotomies developed over serial radiographs. The patient then began using a CAM boot, and weight-bearing ensued in this fashion for a further four weeks. Complete healing of both osteotomies occurred at 12 weeks postop. The patient received a new accommodative foot orthotic, and no recurrent ulceration has occurred.

Final Discussion

This case represents a complication of double osteotomy with capital first metatarsal displacement. Displaced first metatarsal head osteotomies can present a significant challenge to foot and ankle surgeons. Reoperation with the presence of edema increases the risk of hematoma formation and infection. Also, there is a major concern for development of avascular necrosis.¹⁵ Although the rates of avascular necrosis of the first metatarsal head after a distal osteotomy for hallux valgus vary significantly in the literature, reports cite anywhere from zero to 50 percent.¹⁶ Revision surgery can increase these rates; however, it is widely regarded that with appropriate dissection technique, one may spare vascular supply to the head of the metatarsal. Clinical presence of infection was also a complicating factor, as well as limited real estate for additional fixation. Displacement, in this case, also resulted in comminution of the dorsal wing. A 0.062-inch K-wire used axially is extremely helpful with these cases, in our experience. In most instances, the plantar wing of the capital fragment at the osteotomy site is intact, and by restoring anatomic alignment at this level, osseous healing occurs as well as normal restoration of weight bearing. The surgeon can backfill the remaining comminuted dorsal wing. With concern for residual infection, closure over vancomycin powder allows soft tissue closure over the osteotomy to preserve its blood supply. Leaving the remaining incisional wound open may decrease the risk of recurrent infection.

This unique case was also complicated with the incidence of the intra-articular hallux proximal phalanx base fracture. The external fixator concomitantly treated this fracture by the placement of a pin in the proximal phalanx to appropriately distract the metatarsophalangeal joint while simultaneously compressing the osteotomy site of the first metatarsal. This allowed for proper healing at the fracture and osteotomy site.^9,11 The dynamic applications of the external fixator make it a viable option for revision procedures in failed hallux valgus surgery without sacrificing the metatarsophalangeal joint space, which are vital considerations when planning for surgical interventions of this nature. 

Dr. Visser is the Podiatric Residency Director at SSM Health DePaul Hospital in St. Louis. He is a Diplomate of the American Board of Podiatric Medicine and the American Board of Foot and Ankle Surgery.

Dr. Farr is a second-year podiatric resident at SSM Health DePaul Hospital in St. Louis.

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