metatarsat osteotomy for the correction of metatarsus adductus

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