Lesser metatarsal surgery (Surgery) Flashcards
What are the surgical approaches for IPK or Intractable Plantar Keratosis?
1?
2?
3?
- Excision of scar
- Plantar condylectomy
- Osteotomy: Shortening/ Elevation
Simple Excision
Advantages:
1?
2?
3?
Disadvantages:
4?
- It’s simple
- Removes deep adhered scar tissue
- Replaces a thick tortuous scar with a thin pliable scar
- Creates another potentially painful scar
- What are the indications for Simple excision of IPK?
- What are the contraindications for simple excision of IPK?
- Pain, no lesser metatarsal deformity, no history of trauma to the foot
- History of Keloid scars
Plantar Condylectomy
Through 1? incision
Release of 2?
Removal of about 3?
- dorsal
- collateral ligaments (based on the book: transverse metatarsal ligament, collateral ligaments and capsule)
- 25% of metatarsal head
What are the complications with plantar condylectomy?
1?
2?
3?
4?
5?
- Instability of MPJ
- “Floating toe”, one way to avoid this is to tape the toe down after the procedure
- weakend the MPJ apparatus
- Transverse metatarsalgia
- You might get dorsal contracture and a bit of stifness
What surgical technique can be employed?
How does this osteotomy help to relieve pressure from
beneath the metatarsal head?
Weil osteotomy
to shorten lesser metatarsals, you open the foot from the dorsal, make a cut and push the metatarsal to the back it shortens it, so you elevate it as well
What are the different shortening techniques?
1.?
- Double “V” shortening osteotomy, in the metaphyseal area, heel quicker because the blood supply is much much better at the metaphaseal area
What is the other shortening technique?
Sagittal Zed shortening osteotomy
mid metatarsal area
more correction
lots of space
for fixation (e.g. wires or screws)
What is the dorsal osing wedge osteotomy?
This procedure is used to correct painful IPK formation secondary to a plantarflexed metatarsal. It is performed at the base which affords a rich source of blood flow within the metaphyseal bone, 1cm distal to the metaphyseal cuniform or metatarsal cuboid articulation. The osteotomy begins dorsally but does not pass through the plantar cortex of the bone. An angled dorsal wedge cut is made to allow for dorsiflexion of the involved metatarsal, which is held securly with internal fixation of the surgeon’s choice. Immobalisation and non-weight bearing is recommended for a period of 6 to 8 weeks.
What are some of the disadvatnages of Dorsal closing wedge osteotomy?
if you take too much you’ll elevate it too much(dis)
not stable (dis)
What’s the Wilson’s sliding osteotomy?
Dis/Adv?
A transverse osteotomy is a straight through-and-through cut from dorsal to plantar to located in the surgical neck of the bone.
Benefits:
1. despite allowing motion in all 3 planes PMO (percutaneous metaphyseal osteotomy) offers stability because the collateral ligaments remain intact.
2. minimal periosteal disection allows for decrease in pain as well as leaving a good source for osteoprogenitor cells intact to allow for healing.
What is the procedure to avoid out of the lesser metatarsal surgeries?
Why?
Transverse base wedge closing osteotomy
What are the clinical findings with Tailor’s bunion?
- Overall appearance
- Hyperkeratosis
- Location…
- 5th MPJ ROM
- 5th Met head
- pain
- Bursitis
What are shown in the radiographic evaluation?
1?
2?
3?
- 4-5 IM Angle
- Lateral bowing
- Apex of deformity
Based on the book
For metatarsald with a high degree of metatarsal bowing or intermetatarsal angulation a 1? procedure is indicated.
For those metatarsals in which bowing is insignificant or absent and the intermetatarsal angle approaches normal 2? is recommended.
- Base
- Head procedures with prominence resection
When would you perform the complete metatarsal head resection?
- failure of previous surgery
- Bone infection,
- elderly
What are the 3 main 5th metatarsal surgical procedures?
1?
2?
3?
- Partial osteotomy of the metatarsal neck
- Reverse Wilson slide osteotomy of the metatarsal neck
- Closing adductory base wedge osteotomy
What are the different Fixation techniques?
1?
- K‐wires ‐ Kirschner wires or pins are thin stainless steel pins, Adv: Cheap, easy to use DisAdv: Don’t give compression, they can get lose later on so they can be replaced or removed later on.
- Staples ‐ either made from k‐wires (noncompressive) or compressive
- Wire – monofilament ss wire
- Screws – cancelous, cortical or cannulated
Adv: Compression Disadv: 250$ very expensive
Cancellous screws
1?
2?
Cortical screws
3?
4?
Cannulated screws
5?
- Remain within cancellous bone,
- wide thread pitch
- cross both cortices
- tight thread pitch
- self screwing
Which one is the corticol and which one is the cancellous screw?
Orange: Corticol
Blue: Cancellous
What are the complications with Tailor’s bunion surgery?
- Fixation Failure
- Fracture: post-operative fracture if they walk too much on it
- Delayed Union/Malunion
- Under-correction /Over-correction
- Floating 5th Toe
- Transfer Lesions
What has been performed here?
Red arrow?
How many days post-op?
Red arrow: double V-osteoctomy with no fixation
Austin procedure metatarsal heads been shifted laterally and fixated with the K- wire position of the K-wire is obligue. it’s percutaneous (stikking out of the skin) so this is an old x-ray
adv: they can take it out easily
dis: infection!
3-4 weeks post op because of the callus formation
What’s the loop wire technique:
1?
2?
- Transverse wedge in the metatarsal neck
- Circlage wire fixation (22g)
What are the advantages of Loop Wire technique?
1?
2?
3?
4?
5?
- Dissection and Exposure
- User friendly osteotomy
- Good Bone to Bone Contact
- Stable once fixated
- Weight-bearing
What are some other benefits of loop wire technique:
1?
2?
3?
4?
5?
- Stable Osteotomy that provides
- good correction
- Weight-bearing Procedure
- Predictable Bone Healing
- Reproducible
Freiberg’s disease
- What is it?
- What could be some of the causes?
- Bilateral of Unilateral?
- Age raneg?
- Tx options?
- Avascular necrosis of lesser metatarsal head
- Trauma, Long metatarsal
- Unilateral usually
- Wide age range
- Rest, immobalisation, Surgery
What are the surgical options for Freiberg’s disease?
1?
2?
- Joint debridement
- Shortening or dorsiflexory osteotomy:
In symptomatic cases unresponsive to conservative care
Dorsiflexory osteotomy Reduces ‘bulk’ of met head
