Complications in Distal Minimally Invasive Metatarsal Osteotomies: Systematic Review and Meta-Analysis

Abstract

Background and Objectives: Minimally invasive distal metatarsal osteotomy (DMMO) has established itself as an effective surgical technique for the treatment of metatarsalgia, notable for its reduced postoperative pain and faster recovery. However, doubts remain regarding the frequency and nature of postoperative complications. The objective of this systematic review and meta-analysis was to evaluate the incidence of the most frequent complications associated with the DMMO technique, including prolonged edema, delayed bone healing, transfer metatarsalgia, floating toe, and persistent pain. Materials and Methods: A systematic review was conducted following the PRISMA 2020 guidelines, with the protocol registered in the PROSPERO database (CRD420251067666). Searches were conducted in the PubMed, Scopus, and Web of Science databases, including clinical studies published between 2010 and 2025. The inclusion criteria covered studies in adults treated with DMMO and reporting postoperative complications. The methodological quality assessment was performed using Joanna Briggs Institute (JBI) tools according to the design of each study. Random-effects models were used for the meta-analyses, assessing heterogeneity using the I² statistic. Results: Fifteen studies with a total sample of more than 493 patients were included. Prolonged edema was the most common complication (30.91%), followed by delayed bone healing (14.9%), transfer metatarsalgia (12.73%), floating toe (10.45%), and persistent pain (8.5%). Less frequent complications included nonunion, infections, necrosis, and bone misalignments. The combined incidence of floating toe was 40% (I² = 0%), while prolonged edema showed considerable heterogeneity (I² = 88.3%). The overall quality of the evidence was considered moderate to low, mainly due to the predominance of observational studies. Conclusions: The DMMO technique represents a minimally invasive surgical option with generally favorable results. However, some complications, such as prolonged edema and floating toe, have a significant incidence. The methodological variability between studies highlights the need for standardized protocols and higher-quality prospective studies to establish the safety profile of this technique more accurately.

Keywords: DMMO (distal minimally invasive metatarsal osteotomy); MIS (minimally invasive surgery); complications; meta-analysis; metatarsalgia.

Figure 1

PRISMA flowchart of the article selection process.

Figure 2

Forest plot: delay in consolidation [16,20,21,26,28,32].

Figure 3

Forest plot: transfer metatarsalgia [16,20,26,27,28,29,31,32].

Figure 4

Forest plot: floating toe [27,32].

Figure 5

Forest plot: persistent pain [27,29,32].

Figure 6

Forest plot: prolonged edema [16,18,20,27,29,33].

Figure 7

Funnel plots for detecting publication bias in the different analyses of postoperative complications: (a) bone consolidation; (b) transfer metatarsalgia; (c) floating toe; (d) persistent pain; (e) prolonged edema [16,18,20,21,26,27,28,29,31,32,33].