Osteotomy of the Three Central Metatarsals

- Approach. Skin incision: Dorsal, one incision for one or three metatarsals. The proximal intermetatarsal edge is checked with the scarf graduated ruler.

- The osteotomy begins dorsally at 1.5cm from this edge. It is 60° plantar and proximal directed, respects the intermetatarsal articular surfaces and reaches the proximal and plantar parts of the metatarsal in a part where the can-

cellous bone and the cortex provide favorable conditions to preserve the proximal hinge with sufficient elasticity when closing the osteotomy.

- A second cut may be performed but it is better to enlarge the first one instead of performing a second cut, in order to avoid too much elevation.

Three rules for this osteotomy:

a) To have sufficient obliquity in order to reach the very plantar aspect proximally and to have a long cut.

b) To carefully preserve the proximal hinge.

c) Not to elevate the metatarsal too much.

- The amount of metatarsal elevation, i.e. the size of the bony wedge which will be removed,

Brt Osteotomy

Fig. 18b1. BRT osteotomy. Operative technique 1.

1, 2. Approach through a longitudinal incision for one or for the three median metatarsals.

3. The cut begins on the dorsal metatarsal aspect 1 to 1.5 centimetre from the intermetatarsal proximal edge.

4. The cut has a 60° plantar and proximal oblique direction.

5. Cut not enough oblique: Rupture of the plantar cortex.

6. Correct obliquity of the cut: The proximal hinge is preserved.

Fig. 18b1. BRT osteotomy. Operative technique 1.

1, 2. Approach through a longitudinal incision for one or for the three median metatarsals.

3. The cut begins on the dorsal metatarsal aspect 1 to 1.5 centimetre from the intermetatarsal proximal edge.

4. The cut has a 60° plantar and proximal oblique direction.

5. Cut not enough oblique: Rupture of the plantar cortex.

6. Correct obliquity of the cut: The proximal hinge is preserved.

Fig. 18b2. BRT osteotomy. Operative technique 2.

Removing of the dorsal distal wedge (1, 2). Coaptation of the fragments (3).

4, 5. Firstly K-wiring, then setting of the cannulated drill.

6. Screw measuring with a depth gauge.

7, 8, 9. Setting of the screw which ensures the fragmental contact.

Fig. 18b2. BRT osteotomy. Operative technique 2.

Removing of the dorsal distal wedge (1, 2). Coaptation of the fragments (3).

4, 5. Firstly K-wiring, then setting of the cannulated drill.

6. Screw measuring with a depth gauge.

7, 8, 9. Setting of the screw which ensures the fragmental contact.

has to be clinically assessed during the surgery, above all by palpating the metatarsal heads, which is common for all osteotomies without exposure of the metatarsal heads. We can also assess this elevation amount by plantar flexion of the MTP, which indicates the position of the metatarsal heads (Fig. 18b3). At last, the oblique X-ray view (or fluoroscopy) may also be useful. Only 2mm distance between the two fragments in the dorsal aspect elevates the metatarsal head up to 4mm.

- The fixation: After closing the osteotomy wedge, the distal fragment is held in a dorsal position while the dorsal fragment is maintained. A Kirchner wire is first set, then a cannulated drill (or directly a threaded pin). Then we measure screw to be placed with a depth gauge. The screw is a threaded head, preferably the FRS self-cutting screw, set around K-wire. We observe the good coaptation of the fragment due to the screw compression effect.

Brt Osteotomy

Fig. 18b3. BRT osteotomy. Operative technique 3.

1, 2. Since this osteotomy is clinically assessed, the callus has to be previously removed.

3. Another clinical assessment of the metatarsal head position in a sagittal plane is made by plantar MTP flexion.

4. In this position, pre and postoperative aspects of the same foot.

5. The medial oblique X-ray view can also help to assess the metatarsal sagittal position. Care has to be taken not to elevate too much the metatarsal.

Fig. 18b3. BRT osteotomy. Operative technique 3.

1, 2. Since this osteotomy is clinically assessed, the callus has to be previously removed.

3. Another clinical assessment of the metatarsal head position in a sagittal plane is made by plantar MTP flexion.

4. In this position, pre and postoperative aspects of the same foot.

5. The medial oblique X-ray view can also help to assess the metatarsal sagittal position. Care has to be taken not to elevate too much the metatarsal.

Fig. 18b4. BRT osteotomy. Operative technique 4.

1, 2. When MTP joint release is necessary, it is performed through another incision.

How To Reduce Acne Scarring

How To Reduce Acne Scarring

Acne is a name that is famous in its own right, but for all of the wrong reasons. Most teenagers know, and dread, the very word, as it so prevalently wrecks havoc on their faces throughout their adolescent years.

Get My Free Ebook


Post a comment