A short first metatarsal can lead to transfer metatarsalgia of the second and third metatarsal heads and is unsightly. Many people elect to undergo a lengthening procedure, but metatarsal lengthening for brachymetatarsia is a deceptively simple operation. Surgery can lead to stiffness or subluxation of the MP joint, deformity of the metatarsal, or nonunion at the lengthening site. This case will review a method for salvage of a failed lengthening of the first metatarsal.
This is a 25 year old woman who underwent lengthening of her first metatarsal for brachymetatarsia. The lengthening procedure resulted in poor regenerate formation and deep infection of the lengthening site. The infected regenerate was debrided and an antibiotic bead placed in to the wound. The patient presented with a medial draining sinus still wearing the external fixator.
A staged treatment approach was utilized:
The basic principles for the treatment of an infected nonunion apply to this situation: eradicate the infection with debridement and local and systemic antibiotics, autologous bone grafting v bone transport to fill the defect, stable fixation to allow union. The preservation of length was an important goal in this case. The patient had already sacrificed much effort towards obtaining a longer metatarsal and wanted to maintain that length. Another option was to shorten the metatarsal back to the pre-lengthening position and compress until union.
The mini-external fixator can be applied dorsally or medially to the metatarsal. The revision external fixator pins were placed from the medial side in order to avoid the previous loose pin sites that were placed dorsally. The most proximal pin was advanced into the second metatarsal in order to further improve the purchase and stability of the frame.
If the first MP joint were viable then an additional set of pins would be placed in order to distract the first MP joint.
The axial pin prevents dislodging of the graft during compression of the fixator.
The placement of half pins directly into the autograft should be avoided both for fear of infection and for fear of compromising the structural strength of the graft.
Pin purchase and fixation in general in the metatarsal is less than ideal. This makes pin loosening a real problem. The best way to avoid loosening is protective weight bearing during the entire healing period. The orientation of the metatarsal transverse to the ground imparts a bending moment to the bone upon weight bearing. This is unlike the tibia and femur with their vertical orientation. This further supports the need for minimal weight bearing during the healing phase of the bone graft incorporation.
I strongly believe in autograft for this procedure. Allograft will have a more difficult time healing and is subject to stress fracture with time.
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