Brachymetatarsia is a congenital (present at birth), shortening of the toe, where there is a disturbance to the growth of the toe. It happens most commonly in the fourth toe, although it could affect any toe.  The toe itself is usually of normal length, but the bone to which the toe attaches in the arch (the metatarsal bone) is short. It is sometimes described as a floating toe. It occurs more often in women that in men, is often bilateral (both sides).

Non-surgical options are aimed at decreasing symptoms and include :

  • Supportive shoes or shoes with a wide toe box
  • Custom foot orthotics
  • Activity modifications
  • Spot stretching of shoes by shoemaker
  • Anti-inflammatory medication for the pain

Common indications for lengthening:

  • Pain associated with the short toe
  • Difficulties with shoe wear such as rubbing and irritation of the shorter toe
  • Shorter toe causing functional limitations for walking/sports
  • Appearance of the toe (cosmetic and social impacts)

Evaluation includes:

  1. Comprehensive clinical evaluation of the foot and ankle
  2. Radiographic evaluation of the metatarsal parabola and the difference in length needed to re-establish a normal curve.

X-rays are done in order to allow for accurate surgical planning and assessment of the metatarsal deformity. They include:

  1. Weight bearing anteroposterior (AP) x-rays
  2. Lateral and medial oblique foot and ankle x-rays.

 

Surgical Techniques:

The aim of the surgery is to lengthen the metatarsal bone and this can be done using one of the following procedures. The choice of the procedure depends on the length that is to be acquired.

Acute lengthening with bone graft

If the toe requires lengthening of 12 mm or less, it can be corrected using a bone-grafting procedure.

Technique:

  • General or regional anasthesia is given
  • The bone graft is then taken from your iliac crest (pelvic bone)
  • An incision is made on the short toe and the extensor tendons are lengthened in a Z fashion
  • The bone is then exposed and cut using a saw.
  • The short bone is then distracted by a spreader and the graft is inserted into the space.
  • The graft is held in place with a wire that transverse the toe. This wire also helps keep the other joints stable.
  • A rigid heel post-operative sandal is used post-operatively for walking.
  • The wire is removed from the toe about 6 weeks after sugery.

Gradual lengthening with external fixation

If the toe requires lengthening that exceeds 12mm, then gradual correction is done using an external fixator.

Technique:

  • General or regional anasthesia is given
  • An incision is made on the top of the foot to lengthen the extensor tendons in a Z-fashion. The incision is then closed.
  • 4 pins are inserted into the short toe, aligned with the axis of the toe
  • A small cut in the skin is made and the short bone is cut in the middle of the 4 pins.
  • An external fixator is placed on the 4 pins and 1mm of distraction is done under xray to ensure that it is functionning properly and that the bone is lengthening.
  • A K wire is then inserted into the toe from the top to stablize the joint above the lengthening.
  • The incision is closed and bandages are placed.
  • A rigid heel post-operative sandal is used post-operatively for walking.

Lengthening starts approximately 1 week after surgery.  The patient has an allen key that they use to turn ( ¼ turn 2 times a day or as instructed) to lengthen the toe. Once the desired length is reached, turning stops and consolidation of the bony healing continues.  The device is removed once the bone is completely healed.

Example of gradual lengthening with external fixation at the end of correction

 

The toe lengthening surgeries are usually performed as outpatient surgery, meaning that the patient can go home on the same day. The aenesthesia performed is dependent on the extent of the surgery. It can be performed under regional or general anesthetic.

Bilateral surgeries are only considered after thourough discussion with the patients due to higher risks of complications and functional incapacity.

Post operative care

The recovery time after a brachymetatarsia surgery depends on the procedure performed and on the amount of lengthening required.

For acute lengthening, recovery time is approximately 3 months.  Patients are permitted to walk on their heel until 6 weeks after surgery and then they are encouraged to walk on their entire foot to help heal the graft.

For gradual lengthening with the external fixator, recovery time varies depending on the length desired and the speed of bony consolidation.  Typically patients can expect to have the external fixator on their foot for 4-6 months. Patients are permitted to walk on their heels during the lengthening phase and encouraged to increase their weight bearing to their foot once desired length is achieved.

These are general guidelines please always follow the instructions provided by Dr Gdalevtich.

Follow-up appointments with Dr Gdalevitch:

For acute lengthening your follow up appointements and repeat xrays will be at 2 weeks, 6 weeks, 3 months and 6 months post-operatively.
For gradual lengthening, your follow up appointements and repeat xrays will at 1 week and then every 2 weeks until the desired length is achieved.  Once the length is achieved, follow up is every 4 weeks with xrays until bony healing is complete.

Potential risks and complications include:

  • Infection (superficial or deep)
  • Pain (temporary or permanent)
  • Swelling
  • Delayed union, non union or mal union of the bone
  • Over lengthening
  • Premature consolidation (for gradual lengthening)
  • Subluxation of toe
  • Stiffness of toe
  • Metatarsalgia
  • Fracture of toe

For a complete list of the risks and complications, please see Patient Info, under the Preoperative information.

Patients who will undergo this procedure should read the following sections