metatarsat osteotomy for the correction of metatarsus adductus

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AFig. 3. Diagrammatic representation of determination of metatarsusadductus angle by Whitney. A. Plotting of critical points and determinationof longitudinal bisector of lesser tarsus. B. Lesser tarsus axis isrepresented by the bisection of the longitudinal bisector of the lessertarsus. C. Diagrammatic representation of the metatarsus adductusangle (see text for complete details).ln the following section the various modifications ofthe Berman and Cartland procedure will be examined,the different types of fixation will be discussed as wellas the complications and postoperative management.The soft tissue dissection has been discussed elsewhereand will not be addressed.Over the past fifteen years the staff of the PodiatryInstitute has used a combination of procedures for thecorrection of metatarsus adductus in the child age sixand older with moderate to severe metatarsus adductusunresponsive to conservative therapy. ln addition theseprocedures are used for the correction of symptomaticresidual metatarsus adductus in the patient withpreviously corrected talipes equinovarus.Modified Berman-Gartland Procedu reFig. 4. Alternative method of determining metatarsus adductus angleaccording to Engel.The modified Berman-Cartland procedure uses eithertransverse base wedge osteotomies or oblique basewedge osteotomies of the metatarsals with internal fixationof stainless steel wire, Kirschner wire (K-wire), smallbone staples or small bone screws (Fig. 5).245
Fig.5. Preoperative and postoperative radiographs of metatarsus adductusrepair using modified Berman and Cartland procedure.The Modif ied Berman-Cartland usually employs threedorsal longitudinal skin incisions and the principles ofanatomic dissection. The periosteum of each metatarsalmust be preserved with great care when exposing theproximal metaphyseal region. Nowhere is this moreimportant than in exposing the base of the f irst metatarsal.ldentification of the epiphyseal growth plate is criticalto avoid damaging it during the osteotomy, and oneshould avoid excessive reflection of the periosteum surroundingthe growth plate (Fig. 6).Prior to performing the osteotomies the surgeon mustdecide upon the sequence of execution of multiplemetatarsal procedures. This will vary with the preferenceand experience of the surgeon. Common patterns forperforming the osteotomies are 5-1-2-3-4 and 1-2-3-4-5. Insevere deformities, it may be difficult to reduce theadduction of the first metatarsal after osteotomy withoutfirst completing osteotomies on the adjacent metatarsals.ln some cases it may not be necessary to to perform anosteotomy on the fifth metatarsal to achieve correction.The staff at the Podiatry Institute has further modifiedthe technique of Berman and Cartland to use closingabductory base wedge osteotomies of the first and fifthmetatarsal as opposed to transverse base wedgeosteotomies. The oblique base wedge osteotomiesfacilitate the use of AO/ASIF internal fixation techniqueswith small cortical or cancellous screws.The fifth metatarsal is identified through the lateralincision, the periosteum is incised in a linear mannerover the base and proximal portion of the shaft. TheFig. 6. Clinical photo of epiphysis of first metatarsal. Note identificationof first metatarsal cuneiform articulation.insertion of the peroneus brevis tendon should not bedisturbed. lf a peroneus tertius is present then theperiosteal incision should be placed laterally. An obliqueosteotomy is performed from distal-lateral to proximalmedialpreserving a medial cortical hinge. The osteotomyis placed such that it is oriented approximately sixtydegrees to the long axis of the metatarsal and Iies in thesagittal plane. To insure that the osteotomy is in the sagittalplane the medial cortical hinge should be perpen-246
Page 1 and 2: METATARSAT OSTEOTOMY FOR THE CORREC
Page 3: Fig. 2. Preoperative radiographs, A
Page 7 and 8: Fig. 9. Diagrammatic representation
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metatarsat osteotomy for the correction of metatarsus adductus

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