Metatarsals
Each foot has five metatarsals. These are the long bones of the foot. They connect the toes to the rest of the foot. They also make the ball of the foot. The lesser metatarsals are the bones that connect to the second through fifth toes (not the first, or big toe).
An osteotomy is a cut made in the bone. It is similar to breaking the bone but in a very controlled manner. A lesser metatarsal shortening osteotomy changes the pressure distribution under the ball of the foot, relieving pain. It also can be used to put a chronically dislocated toe back in position.
Diagnosis
Surgery is appropriate if non-surgical methods have not adequately relieved pain. This procedure is used to alter pressure across the ball of the foot as well as correct toe angulation or dislocation. This is most commonly seen when the toes are abnormally bent (hammertoe or claw toe deformities). Other less involved options may be more appropriate depending on the deformity and symptoms of the patient. However, when the toe is dislocated, the deformity usually is addressed with a metatarsal shortening osteotomy, as just straightening the toe (without shortening) can cause loss of adequate blood flow to the toe which could cause gangrene. Another reason to perform the procedure is to relieve pressure under a metatarsal head. In this case, there is usually a callus and pain in the ball of the foot.
Reasons to avoid this surgery include lack of attempted non-surgical treatment, active infection around the surgical site, lack of adequate blood supply to allow healing, or arthritis at the joint next to the osteotomy. The shortening osteotomy would correct the toe’s position, but the patient would likely have continued pain due to the arthritis.
Treatment
This procedure typically is performed with the patient going home the same day. General and/or regional anesthesia (a block) can be utilized. The surgeon uses a saw to cut the bone. The two bone ends are shifted so that the bone shortens. This shortening gives “slack” to the toe and allows the toe to be placed in the correct position. Other soft tissue procedures often are performed at the same time to correct toe deformities.
Specific Technique
A one to two inch incision is made over the top of the foot. There are many types of metatarsal shortening osteotomies. Where the incision is made depends on the location of the osteotomy. A bone cut is made using a saw at the end of the metatarsal. The cut is made completely through the bone. After the appropriate amount of sliding has occurred, the osteotomy is held in that position with either pins or screws. The surgeon may also place a temporary wire through the toe itself. The skin is then closed.
Recovery
Immediately after surgery, a padded soft dressing is placed around the foot. The patient is given a hard-soled shoe or boot and allowed to place weight only on the heel.
Instructions are given to keep the dressing clean. Showers/bathing can be done with either a plastic bag or commercially available cover to keep the dressings dry. The patient should keep the foot elevated as much as possible to avoid swelling. Excess swelling can lead to problems with wound healing.
The patient usually is seen in the office one to two weeks after surgery. The dressing is changed and when skin has adequately healed, the stitches are removed. Range-of-motion exercises with the toe may be started. If a wire was placed in the toe, it typically is removed in the office four to six weeks after surgery. At 4-6 weeks, weight bearing usually is allowed as tolerated.
Risks and Complications
All surgeries come with possible complications, including the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots. There also are complications specific to metatarsal osteotomies. Failure of the bone to heal after it has been cut may result in continued pain. This complication typically requires another surgery to get the bone to heal in order to alleviate the pain. Excessive scaring can occur as can recurrence of the deformity.
FAQs
Will I have normal function of my toes after this surgery?
You should expect some degree of stiffness of the operative toes after this procedure. The amount of motion regained depends on the severity of the deformity before surgery and any other procedures done. Range-of-motion exercises after surgery can help to decrease stiffness.
How long will my toe be swollen after surgery?
Even with appropriate healing, toes may remain swollen for months after surgery.
