LENGTHENING OF SHORT GREAT TOES BY CALLUS DISTRACTION

LENGTHENING OF SHORT GREAT TOES BY CALLUS
DISTRACTION
YOSHINORI TAKAKURA,
YASUHITO TANAKA,
TADASHI FUJII,
SUSUMU TAMAI
From Nara Medical University, Nara, Japan
We lengthened seven ﬁrst metatarsals in four patients
four patients with a short great toe. We describe the oper-
with short great toes by callus distraction using an
ative procedure and our results.
external ﬁxator. Good clinical and cosmetic results were
obtained. Bone lengthening is effective in patients with
PATIENTS AND METHODS
short great toes not only for cosmesis, but also to relieve
pain and callosities on the plantar aspect of the second
From 1989 to 1994 we treated 22 feet with short great toes
and third metatarsal heads.
in 14 patients conservatively with orthoses, including ﬁve
Excessive lengthening of the ﬁrst metatarsal resulted
with congenital club foot. Of these, seven feet in four
in limitation of the range of movement of the
patients had bone lengthening by callus distraction, three
metatarsophalangeal joint of the great toe. To prevent
being treated bilaterally. All were women with a mean age
this the amount of lengthening should not exceed 40%
of 21 years (20 to 23). Two had bilateral shortening of other
of the preoperative length of the metatarsal.
toes. One (case 1) had shortened third and fourth toes and
the other (case 2) shortened fourth toes. They all had pain
J Bone Joint Surg [Br] 1997;79-B:955-8.
Received 2 May 1997; Accepted after revision 23 June 1997
under the second or third metatarsal heads when walking;
in two patients callosities had formed under the affected
metatarsal heads (Fig. 1). One patient (case 4) had pain on
Brachydactyly of the foot is a congenital deformity in
the medial side of the metatarsophalangeal (MTP) joint of
which one or more toes are abnormally short due to a short
the great toe with hallux valgus (Table I).
1-3
metatarsal; the fourth toe is most commonly involved.
We used a standard dorsoplantar radiographic projection
First-ray insufﬁciency with shortening of the ﬁrst meta-
of the foot: the X-ray beam was inclined 15° from the
8
tarsal was ﬁrst described as ‘Morton’s syndrome’ or ‘Mor-
vertical at a distance of 100 cm. We measured the length
4
ton’s foot’ and becomes obvious in children at about ten
of the ﬁrst and second metatarsals and expressed the length
years of age. The incidence is about one in 10 000; in Japan
of the ﬁrst as a percentage of the length of the second. The
one case was described in 10 918 school children between
mean length of the ﬁrst metatarsal was 65.8% (61.6 to
5
13 and 17 years of age.
71.2). These values indicated severe shortening of the8
This deformity is not only cosmetically unacceptable but
metatarsal, since the normal value is approximately 86%
also impairs the weight-bearing mechanism of the foot.
(Table I). Furthermore, the mean length of the great toe
There is plantar pain, and the formation of callosities on the
expressed as a percentage of the length of the second toe
second and third metatarsal heads give difﬁculty in wearing
was 70.8% (68.3 to 72.6) which is shorter than the 83% of
4,6,7
8
high heels and in walking.
normal feet. Our patients therefore had a shortened meta-
We have performed bone lengthening by callus distrac-
tarsal and proximal phalanx (Figs 1 and 2).
tion (callotasis) with an external ﬁxator on seven feet in
Operative technique. A longitudinal incision of about
3 cm is made on the dorsal side of the ﬁrst metatarsal. The
exposed periosteum is longitudinally incised and carefully
stripped. Four pins, two at the proximal and distal sites, are
inserted for external ﬁxation and the cortex of the meta-
tarsal bone is drilled between the second and third pins
Y. Takakura, MD, Associate Professor
Y. Tanaka, MD, Clinical Fellow
using a Kirschner wire. The bone is divided at the drill site
T. Fujii, MD, Clinical Fellow
with an osteotome, the periosteum and skin are sutured, and
S. Tamai, MD, Chairman and Professor
Department of Orthopaedic Surgery, Nara Medical University, Kashihara,
an external ﬁxator (Orthoﬁx M-ﬁxator 100) attached.
Nara 634, Japan.
The mean waiting period before the lengthening began
Correspondence should be sent to Dr Y. Takakura.
was 12 days (11 to 14). One or two screws on the external
©1997 British Editorial Society of Bone and Joint Surgery
ﬁxator were turned by the patients themselves to obtain
0301-620X/97/67933 $2.00
lengthening from 0.25 mm to 0.75 mm per day based on
VOL. 79-B, NO. 6, NOVEMBER 1997
955

956
Y. TAKAKURA,
Y. TANAKA,
T. FUJII,
S. TAMAI
Fig. 1a
Fig. 1b
Fig. 1c
Fig. 1d
Case 3. Photographs showing bilateral shortening of the great toes (a), the sole of the foot with plantar callosities (b), both feet at 3 years 8 months after
operation (c) and the disappearance of the plantar callosities (d).
Fig. 2a
Fig. 2b
Fig. 2c
Case 3. Radiographs showing a left foot with shortening of the great toe before operation (a), during callus distraction ﬁve weeks
after osteotomy (b) and at 3 years 8 months after operation (c).
THE JOURNAL OF BONE AND JOINT SURGERY

LENGTHENING OF SHORT GREAT TOES BY CALLUS DISTRACTION
957
Table I. Details of four patients who had bone lengthening by callus distraction
Range of movement
MTP joint
Length
Plantar
of ﬁrst
Fixation
Lengthening
Preop
Postop
Age
Other
metatarsal* Other
period
Follow-up
Healing
Case Sex (yr) Side deformity
Pain Callosity
(%)
operations
(wk)
(mth)
mm
%
index
DF/PF
DF/PF
1
F
21
R
3 and 4
+
+
66.5
One-stage
25
63
16.2
40.0
106.1
60/25
30/15
short
lengthening
3 and 4
(bone graft)
L
3 and 4
+
+
66.3
One-stage
22
67
19.0
35.1
81.1
50/20
25/10
short
lengthening
3 and 4
(bone graft)
Shortening
of 2nd
2
F
20
R
4 short
+
-
61.6
Lengthening 15
58
16.5
32.4
63.6
50/20
50/10
4 by callus
distraction
L
4 short
+
-
64.2
Lengthening 10
55
13.5
25.7
51.9
55/25
50/15
4 by callus
distraction
3
F
23
R
-
+
-
71.2
-
17
45
14.0
29.1
85.0
65/20
40/10
L
-
+
+
62.7
-
19
43
19.5
41.4
68.2
60/25
30/10
4
F
22
R
Hallux
+
-
67.9
Mann's
9
37
9.5
16.3
66.3
65/35
45/20
valgus
osteotomy
Mean
21.5
65.8
16.7
52.6
15.5
31.4
74.6
58/24
39/13
* see text
callus formation which was checked on radiographs each
The bone lengthening was successful, but the valgus cor-
week. The usual rate of lengthening was 0.5 mm per day
rection was not satisfactory. This was revised by Mann’s
with continuous callus formation. Distraction was con-
procedure, which does not shorten the ﬁrst metatarsal, with
tinued until the ﬁrst metatarsal was at the same distal level
a good result.
as the head of the second metatarsal or there was severe
We measured movement of the ﬁrst MTP joint with a
limitation of the movement in the great toe.
goniometer on the medial side of the joint. There was a
All patients were allowed to walk with partial weight-
decrease of 33% in dorsiﬂexion and of 46% in plantar
bearing on the day after the operation and were not immo-
ﬂexion (Table I). This showed the tendency for the range of
bilised in a cast or postoperative shoe. They used crutches
movement to decrease inversely with the amount of length-
only for two weeks.
ening of the metatarsal, but could not be conﬁrmed statis-
tically because of the small number of cases.
Postoperative complications included limited dorsiﬂex-
RESULTS
ion of the great toe in two patients (three feet). One patient
Table I gives the details of the patients and the results. The
(case 1) complained of mild pain during dorsiﬂexion on the
mean period of lengthening was 16.7 weeks (9 to 25) which
right side. Plantar callosities had been observed beneath the
included the first waiting period, distraction and the neutral-
metatarsal heads of the second and third toes in three feet in
isation period. The mean lengthening was 15.5 mm (9.5 to
two patients before the operation, but these disappeared
19.5) and the mean healing index, the number of days for
within about six months after the operation (Fig. 1). All
10 mm of lengthening, was 74.6 days (51.9 to 106.1). The
patients but one were able to wear heels of 5 cm and higher
mean postoperative follow-up was 52.6 months (37 to 67).
and to participate in sports, and all were satisﬁed with the
No patient required bone grafting of the ﬁrst metatarsal.
cosmetic result.
In two patients (four feet) lengthening of toes other than the
great toe was performed at the same time. One patient with
DISCUSSION
unilateral hallux valgus (case 4) had bone lengthening and
correction of the hallux valgus with excision of the exo-
The length of the ﬁrst metatarsal in all our patients was
stosis and repair of the medial capsule at the same time.
much shorter than in the normal foot, and all had some pain
VOL. 79-B, NO. 6, NOVEMBER 1997

958
Y. TAKAKURA,
Y. TANAKA,
T. FUJII,
S. TAMAI
on wearing high heels; two had plantar callosities (Fig. 1).
a short hospital stay and allows early walking with normal
6
Viladot suggested that these symptoms indicate ﬁrst-ray
weight distribution. Callus formation is slower in the first
insufﬁciency, and noted that the weakness of the great toe
metatarsal than in the lesser metatarsals, and distraction
3
causes abnormal weight-bearing with increased loading of
therefore takes longer. Another disadvantage is that scar-
the second ray. Treatment therefore requires lengthening of
ring is worse than after one-stage lengthening because the
the ﬁrst metatarsal of the great toe to restore natural weight-
four pins maintain skin tension for some time.
bearing.
In two of our patients (three feet) postoperative limita-
Our measurements showed that the mean length of the
tions of dorsiﬂexion occurred because lengthening excee-
ﬁrst metatarsal in affected feet was 65.8% (61.6 to 71.2) of
ded 40% of the preoperative length of the metatarsal. They
that of the second metatarsal. This severe shortening, less
both had difﬁculty wearing high heels. We therefore recom-
than 75%, compares with the 86% ratio for the normal foot.
mend that the rate of lengthening should not exceed 40%
Furthermore, the mean length of the great toe was shorter
and that active and passive dorsiﬂexion should start soon
8
than in 83% of normal feet. Most patients with a short ﬁrst
after osteotomy.
metatarsal have phalanges which are normal or longer,
No beneﬁts in any form have been received or will be received from a
giving a smaller cosmetic problem. In the rare cases with
commercial party related directly or indirectly to the subject of this
article.
shortening of the metatarsal and the phalanges, there is an
obvious deformity. We believe symptoms and callosities
REFERENCES
develop when the length of the ﬁrst metatarsal is less than
1. Urano Y, Kobayashi A. Bone-lengthening for shortness of the fourth
toe. J Bone Joint Surg [Am] 1978;60:91-3.
75% of the length of the second metatarsal.
2. Wakisaka T, Yasui N, Kojimoto H, Takasu M, Shimomura Y. A
All the patients in our series were able to walk on the
case of short metatarsal bones lengthened by callus distraction. Acta
Orthop Scand 1988;59:194-6.
second day after operation and had no pain during distrac-
3. Magnan B, Bragantini A, Regis D, Bartolozzi P. Metatarsal length-
tion. They were satisﬁed with the results of operative
ening by callotasis during growth phase. J Bone Joint Surg [Br] 1995;
treatment in relieving cosmetic problems, pain and
77-B:602-7.
4. Harris RI, Beath T. The short ﬁrst metatarsal: its incidence and
callosities.
clinical signiﬁcance. J Bone Joint Surg [Am] 1949;31-A:553-654.
There are many methods of lengthening the toes. Skirv-
5. Sugiura Y, Nakazawa O. Bone age: roentgen diagnosis of skeletal
9
ing and Newmann reported one case of lengthening of
development. Tokyo, Chugai-Igaku, 1968:254-7.
bone grafting after distraction. Other methods reported from
6. Viladot A. Metatarsalgia due to biomechanical alterations of the
forefoot. Orthop Clin North Am 1973;4:165-78.
Japan, where shortening of the fourth toe is common,
7. Hughes J, Clark P, Klenerman L. The importance of the toes in
include one-stage lengthening by bone graft, lengthening by
walking. J Bone Joint Surg [Br] 1990;72-B:245-51.
interposed bone graft within the MTP joint, bone graft after
8. Tanaka Y, Takakura Y, Kumai T, Samoto N, Tamai S. Radiographic
analysis of hallux valgus: a two-dimensional coordinate system.
gradual lengthening, and bone lengthening by callus distrac-
J Bone Joint Surg [Am] 1995;77-A:205-13.
1-3,9
tion.
One-stage lengthening by bone graft is not recom-
9. Skirving AP, Newman JH. Elongation of the ﬁrst metatarsal.
mended because muscles and tendons may become tethered.
J Pediatr Orthop 1983;3:508-10.
Gradual lengthening is preferable, and callus distraction
10. De Bastiani G, Aldegheri R, Renzi-Brivio L, Trivella G. Limb
10
lengthening by callus distraction (callotasis). J Pediatr Orthop 1987;7:
without a bone graft is the best method.
This requires only
129-34.
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