Each foot has five metatarsals. These are the long bones of the foot. They connect the toes to the rest of the foot. They also make up the ball of the foot. The lesser metatarsals are the bones that connect to the second through fifth toes (not the first, or big toe).
An osteotomy is a cut made in the bone. It is similar to breaking the bone but in a very controlled manner. A lesser metatarsal shortening osteotomy changes the pressure distribution under the ball of the foot, relieving pain. It also can be used to put a chronically dislocated toe back in position.
Surgery is appropriate if non-surgical methods have not relieved pain. Your foot and ankle orthopaedic surgeon may recommend this procedure to alter pressure across the ball of the foot as well as correct toe angulation or dislocation. This is most commonly seen when the toes are bent abnormally (as in hammertoe or claw toe deformities). Other less involved options may be more appropriate depending on the deformity and the patient's symptoms. However, when the toe is dislocated, the surgeon usually addresses the deformity with a metatarsal shortening osteotomy, since just straightening the toe (without shortening) can cause loss of adequate blood flow to the toe, which could lead to gangrene.
Another reason to perform the procedure is to relieve pressure under a metatarsal head. In this case, there is usually a callus and pain in the ball of the foot.
Reasons to avoid this surgery include lack of attempted non-surgical treatment, active infection around the surgical site, lack of adequate blood supply to allow healing, or arthritis at the joint next to the osteotomy. The shortening osteotomy would correct the toe's position, but the patient would likely have continued pain due to the arthritis.
This procedure typically is performed with the patient going home the same day. General and/or regional anesthesia (a block) can be utilized. The surgeon uses a saw to cut the bone. The two bone ends are shifted so that the bone shortens. This shortening gives "slack” to the toe and allows the toe to be placed in the correct position. Other soft tissue procedures often are performed at the same time to correct toe deformities.
Specific Technique
A 1-2 inch incision is made over the top of the foot. There are many types of metatarsal shortening osteotomies. Where the incision is made depends on the location of the osteotomy. The surgeon uses a saw to cut the bone at the end of the metatarsal. The cut is made completely through the bone. After the appropriate amount of sliding has occurred, the osteotomy is held in that position with either pins or screws. The surgeon may also place a temporary wire through the toe itself. The skin is then closed.
Left: X-ray before surgery. The circle shows the dislocation of the second toe.
Right: X-ray after surgery showing the second toe in the correct position.
Immediately after surgery, a padded soft dressing is placed around the foot. You will be given a hard-soled shoe or boot and instructed to place weight only on the heel.
It is important to keep the dressing clean. You may shower/bathe with either a plastic bag or commercially available cover to keep the dressings dry. You should keep your foot elevated as much as possible to avoid swelling. Excess swelling can lead to problems with wound healing.
The surgeon will usually see you in the office 1-2 weeks after surgery. Your dressing will be changed and, when skin has adequately healed, your stitches will be removed. Range-of-motion exercises with the toe may be started. If a wire was placed in the toe, it typically is removed in the office 4-6 weeks after surgery. At 4-6 weeks, weight bearing usually is allowed as tolerated.
All surgeries come with possible complications, including the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots.
There also are complications specific to metatarsal osteotomies. Failure of the bone to heal after it has been cut may result in continued pain. This complication, called a nonunion, typically requires another surgery to get the bone to heal in order to alleviate the pain. Excessive scaring can occur as can recurrence of the deformity.
You should expect some degree of stiffness of the operative toes after this procedure. The amount of motion regained depends on the severity of the deformity before surgery and any other procedures done. Range-of-motion exercises after surgery can help to decrease stiffness.
Even with appropriate healing, toes may remain swollen for months after surgery.
Original article by Sudhir Belagaje, MD
Contributors/Reviewers: Jeffrey Feinblatt, MD
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