Mini-Invasive floating metatarsal osteotomy for resistant or recurrent neuropathic plantar metatarsal head ulcers

Abstract

Background: Patients with peripheral neuropathy and pressure under a relatively plantar deviated metatarsal head frequently develop plantar foot ulcers. When conservative management with orthotics and shoes does not cure the ulcer, surgical metatarsal osteotomy may be indicated to relieve the pressure and enable the ulcer to heal. The purpose of this study is to evaluate the use of a mini-invasive floating metatarsal osteotomy in treating recalcitrant ulcers or recurrent ulcers plantar to the metatarsal heads in patients with diabetes mellitus (DM) related neuropathy.

Methods: Computerized medical files of patients with diabetic neuropathy treated with an osteotomy during 2013 and 2014 were retrospectively reviewed. There were 20 osteotomies performed on 17 patients (mean age 58 years). The patients had a diagnosis of DM for a mean of 17 years. All ulcers were University of Texas grade 1A; mean ulcer age was 19 months.

Results: After 17/20 operations, the ulcer completely resolved after 6 weeks and did not recur after a mean follow-up of 11.5 months. One patient developed an early post-operative infection with osteomyelitis at the osteotomy site (proximal shaft of the fifth metatarsal) that needed debridement and IV antibiotics. In the other 19 cases, the surgical wound healed within 1 week. Asymptomatic radiological non-union developed in six cases (30 %).

Conclusions: Mini-invasive floating metatarsal osteotomy can cure resistant and recurrent University of Texas grade 1A ulcerations plantar to the metatarsal heads in neuropathic patients.

Keywords: Amputation; Diabetic foot; Metatarsal osteotomy; Prophylactic surgery.

Fig. 1

Surgical procedure for metatarsal osteotomy using a 12 × 2 mm Shannon burr

Fig. 2

Surgical procedure for metatarsal osteotomy using Shannon burr, fluoroscopic view

Fig. 3

Oblique X-ray of patient in following figures, 1 month following surgery. The fifth MT head is significantly elevated and the osteotomy is healing

Fig. 4

Pre-operative view of chronic recurrent ulcer under the fifth MT head

Fig. 5

Ulcer, 6 days after surgery. The ulcer is healing rapidly while the patient is fully weight-bearing

Fig. 6

Ulcer site, 4 months after surgery. The skin under the fifth MT head is almost normal