I am somewhat bemused by the terminology of when
performing lesser metatarsal osteotomies via
minimal incision that they are allowed to "seek
their own level." I suppose I have been
established in practice long enough now to
observe the "old" reinvented as "new."
Complications are a great way to learn, so long
as they are not on your patients.
One of my first surgical cases after
establishing my private practice in New York,
when minimal incision techniques were the "wave
of the future," was on a third metatarsal
osteotomy performed by another podiatrist which
subsequently became dorsally and proximally
dislocated onto the dorsal aspect of that lesser
metatarsal. Not only was the metatarsal head
was "up" but I had no doubt that the surgeon had
his head "up" on some other part of his anatomy.
The technique of creating multiple adjacent
lesser metatarsal osteotomies can create post-
operative osseous "bridging" issues between such
surgically induced fractures. Such complications
are seen when the adjacent osteotomies allow for
excessive periosteal bone formation in the
healing of these osteotomies that are
inadequately fixated. These can create
inappropriate stresses and range of motion
limitation pathologies on these lesser
metatarsal-phalangeal joints, tendon adhesions
and tears, points of pain with shoe wear from
these exuberant osseous healed prominences and
potentials for intermetatarsal space nerve
entrapments.
In regard to the avascular necrosis of the first
metatarsal head experienced with screw fixation,
I would content that it is possible that
excessive periosteal bone dissection of the
first metatarsal is more likely an explanation.
The "standard" of surgical/medical care is
becoming more "nationally" recognized and one
cannot state as a defense any longer that your
selection not to fixate an osteotomy is
a "local" standard or cited in past medical
literature. Regressing to such a standard will
not help your defense in a Court of Law should
you encounter a complication.
Gino Scartozzi, DPM, New Hyde Park, NY,
Gsdpm@aol.com
