Distal metaphyseal metatarsal osteotomy (DMMO) for lesser toe metatarsalgia

NewsBot · Nov 22, 2014

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Outcome of distal metaphyseal metatarsal osteotomy (DMMO) for lesser toe metatarsalgia in a teaching hospital
R. Kakwani, S. Haque, C. Chadwick, M. Davies and C. Blundell
Bone Joint surg proceeding 2014

Introduction: The surgical treatment of intractable metatarsalgia has been traditionally been an intra-articular Weil's type of metatarsal osteotomy. In such cases, we adopted the option of performing a minimally invasive distal metaphyseal metatarsal ostetomy (DMMO) to decompress the affected ray. The meta-tarsophalangeal joint was not jeopardised. We present our outcomes of Minimally Invasive Surgery for metatarsalgia performed at our teaching hospital.

Material and methods: This is a multi-surgeon consecutive series of all the thirty patients who underwent DMMO. The sex ratio was M: F- 13:17. Average age of patients was 60 yrs. More than one metatarsal osteotomy was done in all cases. The aim was to try and decompress the affected rays but at the same time, restore the metatarsal parabola.

It was performed under image-intensifier guidance, using burrs inserted via stab incisions. Patients were encouraged to walk on operated foot straight after the operation; the rationale being that the metatarsal length sets automatically upon weight bearing on the foot. Outcome was measured with Manchester-Oxford Foot Questionnaire's (MOXFQ's) and visual analogue pain score (VAS). Minimum follow up was for six months.

Results: The average MOXFQ score was 26. Average improvement in the visual analogue pain score was 3.5. VAS deteriorated in three patients' whose pain got worse after surgery. Among these three, two had a further procedure on their toes. All of the patients experience prolonged forefoot swelling for at least 3 months.

Discussion: The most common complication after intra-articular ostetomy of the metatarsal head is stiffness of the metatarsophalangeal joint. We believe that using minimally invasive surgery with an extra-articular osteotomy, reduces the soft tissue injury to the joint, and therefore the amount of post-operative stiffness. In our cohort of patients, DMMO is associated with good patient satisfaction and low complication rates in the vast majority of cases.
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Admin2 · Nov 22, 2014

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NewsBot · Mar 12, 2018

Clinical and radiological outcomes after Weil osteotomy compared to distal metatarsal metaphyseal osteotomy in the treatment of metatarsalgia - a prospective study
Jens Kurt Johansen et al
Foot and Ankle Surgery; Article in Press

Highlights
•Compared to the Weil procedure the duration of surgery and tourniquet times were significantly shorter for the DMMO procedure.
•The DMMO offers a good alternative to the WO in treating static metatarsalgia with comparable results to the WO.
•Fewer patients with postoperative stiffness, lack of toe purchase and less reduction in ROM in the DMMO group than in the Weil group, although not statistically significant.
•The DMMO is gaining popularity, but clinical studies are scarce.
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Background
The distal metatarsal metaphyseal osteotomy (DMMO) may have lower complication rates than the Weil osteotomy (WO) due to its extraarticular location and its minimal invasive nature. This study compares the clinical and radiological outcomes and complications after DMMO and WO.

Methods
We compared 30 patients with WO (Group A) to 30 patients with DMMO (Group B). Ten males and 50 females with a mean age of 57.7 were included. 45 WOs and 73 DMMOs were evaluated in 60 patients.

Allocation to Group A or B were random, indications comparable.

The outcome was measured clinically using the Visual Analogue Scale Foot and Ankle and radiologically with an average follow up period of 13 months.

Results
Clinical examination six weeks postoperatively showed swelling of the forefoot in 66.7% for Group A and in 73.3% for Group B. Swelling subsided in the course of time, but postoperative stiffness, lack of toe purchase and range of motion deficits did not change in the course of time. All osteotomies healed. The VAS-FA improved for both groups. Tourniquet time and operating time were lower and radiation doses higher in Group B.

Conclusions
The DMMO resulted in a comparable patient satisfaction and comparable radiological healing compared to WO and appears to be a valid alternative to the WO.
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NewsBot · Jul 6, 2018

Clinical effectiveness and safety of Weil’s osteotomy and distal metatarsal mini-invasive osteotomy (DMMO) in the treatment of metatarsalgia: a systematic review
Amado Rivero-Santana et al
Foot and Ankle Surgery; Article in Press

Abstract
Highlights
•Evidence on the direct comparison of WO and DMMO is scarce and of low quality.
•Studies did not find significant differences in clinical improvement or satisfaction.
•DMMO showed longer time to bone healing but fewer wound problems and less stiffness.
•Randomized studies are needed to draw firm conclusions.
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Background
Weil’s osteotomy (WO) is the most applied surgical treatment for metatarsalgia, a persistent pain in the lesser metatarsals’ heads. We aim to review its effectiveness and safety compared to the percutaneous technique known as distal metatarsal mini-invasive osteotomy (DMMO).

Methods
Systematic review in Medline, Pubmed, Embase, Cinahl and Cochrane Library. We included studies that directly compared WO and DMMO for the treatment of primary metatarsalgia. Data on pain, function, complications and patients’ satisfaction were extracted and narratively synthesized.

Results
Four retrospective studies were identified. There were no significant differences in clinical effectiveness or patients’ satisfaction. Time to bone healing was significantly longer for DMMO, whereas WO showed more wound problems and metatarsophalangeal stiffness. Other complications were infrequent in the two procedures.

Conclusion
Evidence on the direct comparison of WO and DMMO is scarce and of low quality. Randomized studies are needed in order to control for potential confounders.
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NewsBot · May 11, 2019

Evaluation of results after distal metatarsal osteotomy by minimal invasive surgery for the treatment of metatarsalgia: patient and anatomical pieces study.
Lopez-Vigil M et al
J Orthop Surg Res. 2019 May 8;14(1):121

BACKGROUND:
Metatarsalgia of the lesser toes is a common cause of consultation in the podiatric clinic. However, there continues to be a controversy with respect to which is the best surgical technique, and there is few information in the literature regarding objectively comparable results in percutaneous surgery.

METHODS:
The second metatarsal bones of 30 feet belonging to patients who had attended the podiatric clinic were studied before and after distal metatarsal pecutaneous osteotomy. The degree of shortening of the second metatarsal (RX) and the degree of functional recovery and perception of the well-being of the patient (AOFAS) were evaluated retrospectively. The same bones of 10 cadaveric feet were also studied. The surgical procedure was identical to that used on patients, and electronic callipers were employed to take measurements of the second metatarsal. The integrity of the plantar plate was checked visually.

RESULTS:
The mean shortening of the second metatarsal bone, as determined by the radiological study, was 2.76 mm. After an average follow-up period of 1.5 years, the final mean score on the AOFAS scale was 95.26 points. In none of the cases was the mobility of the metatarsophalangeal (MTP) joint affected. The mean shortening in the cadaveric feet was 2.10 mm, and in all cases, the plantar plate and flexor apparatus were perfectly preserved.

CONCLUSIONS:
Percutaneous osteotomy achieved, in our study, a lower degree of shortening than Weil's surgery, according to the data published in the literature. However, it shows good clinical results without causing problems of consolidation or rigidity in the MTP joint. Neither, with the caution that should be taken due to the use of experimental cadaver models, damage of the flexor apparatus of the foot is observed. These results suggest that this could be a safe and effective surgical procedure to be considered for metatarsalgias of the lesser rays.
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NewsBot · Sep 22, 2021

Minimally Invasive Distal Metatarsal Metaphyseal Osteotomy of the Lesser Toes: Clinical, Radiologic, and Pedobarographic Outcomes
Elena Neunteufel, MD, Sabine Krenn, MD, Michel Chraim, MD, ...
Foot & Ankle International August 17, 2021

Background:
The minimally invasive distal metatarsal metaphyseal osteotomy (DMMO) is a percutaneous operative technique with the aim to relieve the symptoms of metatarsalgia. To our knowledge, no previous research has analyzed both pre- and postoperative pedobarographic data including the changes in plantar pressure.

Methods:
Thirty patients (31 feet) were operated on with a DMMO and included in a prospective study. Clinical, radiologic, and pedobarographic outcomes were evaluated in comparison with the preoperative parameters. The American Orthopaedic Foot & Ankle Society (AOFAS) forefoot score, the Foot Function Index (FFI), the Foot and Ankle Outcome Score (FAOS), and a visual analog scale (VAS) for pain were used in order to assess clinical parameters. Radiographs were taken to compare metatarsal lengths. The pedobarographic analysis served to determine plantar peak pressure (PPP) beneath the metatarsophalangeal (MTP) joints.

Results:
All scores indicated a significant mean pre- to postoperative improvement (AOFAS = 31.9 points, FAOS = 16.3%, FFI = 24.3%, VAS pain = 4.1 points, VAS general limitation = 3.3 points) (P < .05). PPP was substantially reduced in the relevant area (M6 [plantar area beneath the second and third MTP joint] had a mean pre to post PPP = 14.15 N/cm2) and concurrently higher in the lateral and medial MTP joint areas (M5 mean pre to post = +14.37, M7 pre to post = +7.11). Our mean metatarsal shortening was 6.6 mm. However, our findings do not demonstrate a significant correlation between metatarsal length relationships and the prevalence of metatarsalgia.

Conclusion:
Our results demonstrate a significant improvement in clinical scores and PPP. A statistically significant relation between metatarsal length and the prevalence of metatarsalgia was not found in this prospective case series
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NewsBot · Oct 8, 2021

Influence of Foot Type on the Clinical Outcome of Minimally Invasive Surgery for Metatarsalgia. A Prospective Pilot Study
Carmen Naranjo-Ruiz et al
Front Surg. 2021 Sep 21

Background and aims: Surgical procedures for central metatarsalgia seek to harmonise the metatarsal parabola with osteotomies that can be performed by minimally invasive techniques. However, the possible relationship of the foot type and the mid-term postoperative outcome is poorly described. The objective of this prospective pilot study was therefore to determine whether the foot type (pronate, neutral, or supinate) conditions the postoperative mid-term functional outcome. Methods: A series of 28 patients (6 men, 22 women) were treated for primary central metatarsalgia by means of minimally invasive distal metaphyseal osteotomy (DMMO). Results: Their functional outcomes at 6 and 12 months were assessed by the self-reporting AOFAS scale. Pre-surgery, the patients' scores were 42.82 ± 15.60. Scores improved at 6 months to 86.50 ± 8.6 and to 92.93 ± 8.6 at 12 months (p < 0.001 in both cases). There were no differences either by sex or by foot type in these overall values, although there was only a slight limitation of interphalangeal mobility in the supinated feet (p = 0.03) at 6-month follow-up as compared to other foot types. Conclusion: Hence, DMMO provides an optimal clinical and functional outcome for the surgical treatment of metatarsalgia, regardless of the patient's foot posture. The occurrence of adverse events was minimal and clinically irrelevant
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NewsBot · Mar 18, 2022

Medium- Long Term Clinical Outcome of Distal Metaphyseal Metatarsal Osteotomy (DMMO) for Lesser Toe Metatarsalgia
E. Ekpo, E. Inegbedion, T. Ball
British Journal of Surgery, Volume 109, Issue Supplement_1, March 2022, znac039.285, https://doi.org/10.1093/bjs/znac039.285

Aim
The surgical management of metatarsalgia is usually with an intra-articular Weil’s type of metatarsal osteotomy. Minimally invasive surgery has become increasing successful for a variety of forefoot conditions. Performing a distal metaphyseal metatarsal osteotomy to decompress the affected ray may result in substantial improvement to quality of life. The aim of this study was to evaluate the outcome of patients following minimally invasive distal metaphyseal metatarsal osteotomy surgery (DMMO).

Method
This is a single-centre consecutive series of 12 patients who underwent DMMO. The aim was to decompress the affected rays and restore metatarsal parabola. DMMO was performed under image intensifier, using burrs inserted via stab incisions. Clinical data was recorded and pre-operatively and immediately post operatively Manchester-Oxford Foot Questionnaire (MOXFQ) scores were collected. Another MOXFQ score was then collected with a minimum follow-up period of 12 months to ascertain is scores had improved in the interim.

Results
Average age of patients was 57years. The sex ratio was M:F 8:4. The average pre-operative MOXFQ score was 36. The average immediate post-operative MOXFQ score was 25. The average follow-up MOXFQ was 16. The reduction in MOXFQ score with a minimum of 12 months follow up was statistically significant (p<0.0040)

Conclusions
DMMO is a safe and effective method for the treatment of metatarsalgia with low complication rates. Our study highlights that clinical improvement of patient’s symptoms may take up to 12 months and beyond following surgery. This should be reiterated to patients prior to surgical intervention.
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NewsBot · Apr 22, 2022

Clinical results of treatment of mechanical metatarsalgia without first metatarsal involvement
J De Prado-Ripoll et al
Acta Ortop Mex. Sep-Oct 2021;35(5):411-416.

Objective: To analyze the clinical results of metatarsalgia treated with percutaneous distal metatarsal metaphyseal osteotomies (DMMO).

Material and methods: Prospective and continuous study of 29 patients with isolated unilateral mechanical metatarsalgia, operated on with DMMO, with a mean follow-up of 38 months. The mean age of the patients was 58 (range: 50-67) years and only two men. We use the AOFAS score, we obtained the digital and metatarsal formulas on the X-rays. We record the subjective assessment of the surgeon and the patient at the end of the treatment.

Results: The improvement in the final score exceeded 80 points in all cases (p = 0.000), with a significant improvement in pain (p = 0.000) and calluses (p = 0.000), improving metatarsal-phalangeal joint stability and interphalangeal and metatarsal alignment. The type of footwear did not change after surgery, we found no variation in mobility, neither in the metatarsophalangeal joints (p = 0.382), nor in the interphalangeal joints (p = 0.672). After surgery increased the square foot morphology (p = 0.027) but the metatarsal formula underwent few modifications. Patients and surgeons were in 96% of the cases "very satisfied" or "satisfied".

Conclusion: DMMO achieves a high degree of satisfaction in patients and in the surgeon, pain and hyperkeratosis under the head of the painful metatarsals disappear and that significantly improves the functional capacity of patients.
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