Correction of Brachymetatarsia: Revisiting the One-Stage Technique

Brachymetatarsia is a general term used to describe a shortening of one or more of the metatarsals.  Typically it affects the 4th metatarsal in women.

Many women who have the condition sometimes complain of pain to the shortened digit or pain under the ball of the foot.  More importantly, some have a deep-seated, self-consciousness about this deformity.  Some may complain that they just don’t want anyone to see their feet and avoid sandals and going bare-footed.

The psychological despair most patients perceive because of this deformity and the eventual correction can be life altering.

Dr. Kline is one of a handful of surgeons in the world who perform the one-stage correction technique.  This implies a one-surgical approach to lengthening the metatarsal with a bone graft without the use of an external fixator.

In 2009, Dr. Kline published an article in the Foot and Ankle Online Journal describing the one-stage lengthening procedure for brachymetatarsia using a single pin technique. (Brachymetatarsia: One-Stage Correction using a Cadaver Bone Allograft, FAOJ, May, 2009).

4th metatarsal brachymetatarsia in a young 13 year old girl prior to one-stage correction of the deformity.
4th metatarsal brachymetatarsia in a young 13-year-old girl prior to one-stage correction of the deformity.
4th metatarsal brachymetatarsia in a young 13 year old girl six months after correction. The length of the metatarsal was restored.
4th metatarsal brachymetatarsia in a young 13-year-old girl six months after correction. The length of the metatarsal was restored.

Since that time, Dr. Kline has modified this procedure using a small plate and screw system.

In 2010, Sandro Giannini, MD, et. al. performed a retrospective study of 29 patients (41 feet) who underwent the one-stage procedure using Allograft with single pin fixation and reported that “Bone union was achieved in all cases. The mean preoperative American Orthopaedic Foot and Ankle Society score was 37 points (range, 28–53 points) and the mean postoperative score was 88 points (range, 74–96 points), with an average improvement of 51 points. Radiographically, the mean gain in length was 13 mm (range, 10–15 mm), and the mean percentage increase was 23%.” (Clin Orthop Relat Res. 2010 Jul; 468(7): 1933–1942.)

The one-stage procedure is one of the most commonly sought after procedures for the correction of brachymetatarsia.  There are basically 2 procedures used to correct brachymetatarsia;  1) the one-stage lengthening or  2) callus distraction using an external fixation device.

“Most of my patients ask for the one stage procedure because they don’t want the frustration of having an external device attached to their foot.”  There are both advantages and disadvantages of this technique.

Use of the mini-rail external fixation device for the correction of brachymetatarsia. (Courtesy Thomas Merrill, DPM, et. al., 15 Diagnoses, 9 Surgical Procedures, 1 Device – Multiple Applications of the MiniRail, FAOJ 5 (8): 2, 2012)
Use of the mini-rail external fixation device for the correction of brachymetatarsia. (Courtesy Thomas Merrill, DPM, et. al., 15 Diagnoses, 9 Surgical Procedures, 1 Device – Multiple Applications of the MiniRail, FAOJ 5 (8): 2, 2012)

“I tell all of my patients that lengthening the bone using a bone graft (either cadaver or autologous – from the patient), that there is a chance of graft failure or lack of complete lengthening.  When a callus distractor is used, it will rarely fail unless improperly placed.”

Callus distraction using the external fixator works by sequentially placing stress along the long axis of the bone.  This is achieved by separating the bone using small, daily increments of distraction along an external rail.  This will separate and lengthen the bone.  Although the advantage to this procedure is an almost 100% success rate, the disadvantage is the risk of pin infections and the inconvenience of having an external fixator placed outside the skin.  The patient will also need to return to surgery for pin removal once the lengthening is complete.

One-stage lengthening works by interposing a graft within a lengthened gap of the long bone and then secured by internal fixation such as plate and screws.  The advantage is one surgery without the need for removal of external pins, etc.  Again, most patients prefer this technique because it eliminates the need for an external fixation device.

Recently, Dr. Kline performed another lengthening procedure for brachymetatarsia.

Case Description

The following photos are of a 21-year-old patient who presented to our office with brachymetatarsia.  She had been searching for someone to correct her deformities, but as with many other patient experiences, most doctors will not perform this procedure due to its technical difficulty and lack of experience or training.

“Every patient and every surgery is unique.  In this case, due to such a shortened metatarsal, I prepared the patient for both external fixation and the one-stage procedure.  I do this in case there are intra-operative complications such as vascular compromise to the digit or contracture that will not allow a full distraction.”

4th Metatarsal Brachymetatarsia in a young female prior to surgery to restore the metatarsal length.
4th Metatarsal Brachymetatarsia in a young female prior to surgery to restore the metatarsal length.

 “As you can see in the above photo, the 4th toe is severely contracted.  There was an accordion effect created by years of contracture of the 4th toe.  In the surgical planning of this case, we discussed one-stage lengthening with soft tissue contractural release of the toe.  This includes both capsular contractural release in surgery and skin contractural release with a simple v-y plasty and tendon lengthening.”

On x-ray, there is a significant shortening of the 4th metatarsal of over 10mm in length.  “Since I have been doing these procedures, I have gained a lot of confidence reducing the contracture and achieving the length without any complications.”

The x-ray reveals a signifcant shortening of the fourth metatarsal of over 10mm.
The x-ray reveals a significant shortening of the fourth metatarsal of over 10mm.

“In surgery, a cadaver graft was used (Iliac crest) and cut to size.  Prior to cutting the metatarsal for graft placement, I release the soft tissue contracture at the joint level and perform a dorsal soft tissue skin and tendon lengthening.  I then cut the bone along the midshaft and interpose the cut Iliac crest graft.”

A lateral view of the lengthening using a cadaver graft and dorsal compression plate.
A lateral view of the lengthening using a cadaver graft and dorsal compression plate.
Portable x-rays showing the DP view of the metatarsal lengthening in brachymetatarsia.
Portable x-rays showing the DP view of the metatarsal lengthening in brachymetatarsia.
Dorsal x-ray views of the one-stage lengthening in surgery. Here, the metatarsal length and parabola has been restored.
Dorsal x-ray views of the one-stage lengthening in surgery. Here, the metatarsal length and parabola has been restored.

“I still use the Kirschner wire through the graft to stabilize the graft once it is in place.  However, over the past five years, I’ve been placing external plates over the graft and placing a single screw through the graft to give it more stability.”

After surgery, the patient is placed in a partial cast and given a knee-scooter to stay completely off the foot for 6-8 weeks.  This will allow the graft to incorporate new bone along the gap.  After 6 weeks and depending on radiographic evidence of bone healing, the patient will transition to a walking boot and then shoes.

The first post-operative visit after surgery showing the restoration of metatarsal and digital length.
The first post-operative visit after surgery showing the restoration of metatarsal and digital length.

Brachy After PhotoIMG_0372

6 months after correction

“Already, at the first dressing change, the patient is very pleased seeing the restored length to their toe.  They are even happier knowing that this was done without a bulky, external fixation device attached to the top of the foot. “

“The changes that I see in the patient’s personality and sheer joy of having an aesthetically anatomic restoration of the foot is amazing and very gratifying to me as a surgeon.”

If you have brachymetatarsia or any other foot deformity and would like a consultation, feel free to make an appointment with Dr. Al Kline at 361-884-3984.