Follow Up
Case Presentation
Failed Crescentic Osteotomy
1st Metatarsal

Thanks for the great number of responses to the clinical case presentation last week. CLICK HERE to see the case presentation if you missed it.

I have paraphrased many readers’ responses below. Don’t be offended if your comments do not appear, as there were just too many to print.

I think this proves that we will continue to make use of regular case presentations in this column.

First off, many of you requested the lateral view x-ray, so here it is:

The other 2 x-rays appear below

Thanks again for your contributions !  Read on...

John Steinberg, DPM
Editor - PRESENT

READER FEEDBACK

Resect the non union site and then use autogenous iliac crest to span the deficit. I would lean towards the Synthes locking plate system for fixation of the surgical site. Post-op care would be non-weightbearing for 6-8 weeks or until good bony consolidation is noted

Jason Bottoms, DPM drago642000@yahoo.com
third year resident working with
the Foot and Leg Healthcare Group
Austell, Georgia

Here are two options which I feel may be applicable:
The malalignment indicated by the standard ap views indicate a considerably shortened first metatarsal that is also medially translated. One can appreciate the fatigue fracture that occurred in the second metatarsal shaft and subsequent medial deviation of the second toe due to overload. I believe that there is too much soft tissue contracture and lengthening could be best performed safely and effectively if it is graduated.

Because the IMA is relatively normal one approach would involve a single transverse osteotomy (or laterally based “L” type osteotomy to avoid lateral bone impingement) at the base of the metatarsal located at the level of the deformity (CORA). The osteotomy would allow lateral translation of the shaft followed which would be followed by an application of a medially based multiplanar EBI type of minirail. This would give you the option to perform your lengthening through callostasis in one stage or (Option 2) lengthen without callus distraction and insertion of an intercalary graft (such as a tibial or iliac crest etc) as the second stage procedure. A properly mounted minirail could be applied to affect plantarflexion or tweak the correction simultaneously if necessary.

Michael M Cohen DPM FACFAS
Michael.Cohen1@va.gov
Chief Podiatry Section
Director of Residency
Surgical Service
Veterans Affairs Medical Center
Miami, Florida

Try Kalish V-osteotomy with very long arm, with rigid 2 screws fixation, and you will be able to correct the sesamoids position and at the same time the intermetatarsal space not the angle of course, plus the benefit of elongating a little bit the 1st ray avoiding transfer lesion to 2nd metatarsal and, the best is correcting for the clinical foot deformity that really bothers the patient at this time. Now, if at the distal fragment displacement there is still a prominent medial base, add more saw and power rasp to make it look as close as possible to the real foot anatomy.

Diego Adarve DPM
orthopody@yahoo.com
Senior Podiatry Resident
Jackson South Community Hospital
Miami, Florida

I think a Ludloff or Proximal "L" osteotomy will work. The cut should start from about 1 cm distal to MCJ dorsaly and ends about mid shaft plantarly. The oseotomy can be fixed with two 3.5 or 4.0 partialy threaded screw or an Integra 1st met plate. this will bring the head down and one can lengthen the 1st met again. Also prepare for bone graft if needed. NWB for at least 6 weeks. if smoker tell them to quit.

Amir Hajimirsadeghi, DPM
amir0731@yahoo.com
2nd year Residebt
Scripps Mercy Program, San Diego.

I believe I would use the width of the bone callus to my advantage.... do a transverse (perpendicular to 2nd met axis) osteotomy at the distal aspect of the lateral bone callus, trans-locate the distal fragment laterally, steinmann pin down the shaft to hold the transverse position, remodel/remove the medial aspect of the metatarsal, then apply distractible mini ex fix.

Terry Felts, DPM, FACFAS
drterbear1@aol.com
Director of Podiatric Medical Education
Franciscan Health Systems-West
Federal Way, Washington

 

Loss of fixation at crescentic osteotomy site

1 year post-op