metatarsat osteotomy for the correction of metatarsus adductus

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hinge. lf the cortical hinge f ractures significant instabilitycan result. lt is imperative that adequate stabilization ofthe segments be accomplished. Significant instability canincrease the likelihood of displacement, malalignment,delayed union/ nonunion, pseudo-arthrosis, or osseousbridging. Fixation for transverse base wedge osteotomiescan be accomplished with the following techniques:K-wires used in a percutaneous or buried fashion,fixating individual metatarsals or a single K-wire tostabilize all the metatarsals. Stainless steel wire can beemployed in several ways; in a cerclage fashion, horizontalor vertical mattress, or in combination with K-wiressimilar to a tension band. Small bone staples may alsobe employed.Fig. 11. Fixation of rotational osteotomy using AO technique. Distalmetatarsal segment is rotated into desired position.A f ull discussion of the complications of the obliquebase wedge osteotomy and fixation techniques is beyondthe scope of this paper. The faculty of the PodiatryInstitute has employed screw fixation for oblique basewedge osteotomies for more than ten years with greatsuccess. Essential to the use of AO/ASIF techniques off ixation of the first or f ifth metatarsal is the preservationof a medial cortical hinge. Strict adherence to the AOprinciples decreases the incidence of failure. As previouslymentioned, in the presence of an open epiphysisin the first metatarsal, the osteotomy is performed acentimeter more distally. This technique has been usedboth in correction for metatarsus adductus and injuvenile hallux abductovalgus without reportedincidence of injury to the physis or shortening of the firstmetatarsal.The rotational osteotomy used in the Lepird techniqueoffers a number of advantages over traditional basewedge osteotomies. lt precludes the need for an intactmedial cortical hinge. Secondly, the use of small corticalor cancellous bone screws provides rigid internal com-Fig. 12. Postoperative radiographs of Lepird procedure'249
pression fixation resulting in primary bone healinggreatly and reducing the likelihood of osseous bridgingbetween adjacent metatarsals. Finally, obtaining desiredcorrection is made easier during surgery simply byloosening the screws and repositioning the metatarsalsegments and resecuring the screws.The technique of rotational osteotomies is not withoutits disadvantages. lf the osteotomy is performed too verticalthe screw fixation proves inadequate or may fail,then stabilization of the metatarsal segments will be difficultdue to the through and through nature of theosteotomy. In such a situation fixation would best beaccomplished with a combination of stainless steel wireand K-wire. lf the screw fixation fails during thepostoperative period, the screw may function as a distractingforce resulting in a delayed union, nonunion,malalignment, or pseudarthrosis. The use of internal fixationmay mean removal of hardware in the future anda second surgical procedure.POSTOPERATIVE MANAGEMENTlmmediately postoperative the patient is placed in abelow-knee compression cast for three to five days. Thisis followed by a below-knee non weight-bearing cast forsix to eight weeks. Radiographs are performedperiodically to access the healing process. In selectedcases, the patients may have the cast bivalved permittingearly active range of motion exercise and fasterreturn to normal function.ReferencesBerman A, Gartland JJ: Metatarsal osteotomy for thecorrection of adduction of the fore part of the foot inchildren. J Bone Joint Surg 534:498-506, 1971.Brown JH, Purvis CG, Kaplan EG, Mann l: Berman-Gartland operation lor correction of resistantadduction of the forepart of the foot. / Am PodiatryAssoc 67:841-847, 1977.Dananberg HJ: Functional hallux limitus and its relationshipto gait efficiency. J Am Podiatric Med Assoc76:648-652, 1986.Engel E, Erlich N, Krems I: A simplified metatarsaladductus angle. J Am Podiatry Assoc 73:620-628,1983.Canley JV: Lower extremity exam of the infant. J AmPodiatry Assoc 71:92, 1981.Marcinko DE,lannuzzi PJ, Thurber NB: Resistant metatarsusaciductus deformity (illustrated surgicalreconstructive techniques). J Foot Surg 25:86-94,1986.Root M, Orien W, Weed J, Hughes R: BiomechanicalExam of the Foot. Los Angeles, Clinical BiomechanicsCorp.1971, p 33.Ruch JA, Banks AS: Proximal osteotomies of the firstmetatarsal in the correction of hallux abducto valgus.In McClamry ED (ed): Comprehensive Textbook ofSurgery, vol 1. Williams and Wilkins, Baltimore, 1982,pp 195-211.Ruch JA, Merrill T: Principles of rigid internal compressionfixation and its application in podiatric surgery.ln McClamry ED (ed): Fundamentals of Foot Surgery.Williams & Wilkins, Baltimore, 1987, pp 246-293.Whitney AK: Radiographic Charting Technique.Pennsylvania College of Podiatric Medicine,Philadelphia, 1978, p 98.Yu CV, DiNapoli DR: Surgical correction of halluxvarus and metatarsus adductus. In McClamry ED (ed):Reconstructive Surgery of the Foot and Leg -Update BT.Tucker, GA, Podiatry Institute PublishingCompany, 1987.Yu GV, Johng B, Freirech R: Surgical management ofmetatarsus adductus deformity. Clinics in PodiatricMedicine and Su rgery 4:207-232, 1987.Yu CV, Wallace CF: Metatarsus adductus. ln McclamryED (ed): Comprehensive Textbook of Foot Surgery,vol1. Williams & Wilkins, Baltimore,1987, pp 324353.250
Page 1 and 2: METATARSAT OSTEOTOMY FOR THE CORREC
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metatarsat osteotomy for the correction of metatarsus adductus

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