MIS & central metatarsalgia : Who is Edward Leventen & What is the Formula

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When a surgeon addresses central metatarsalgia, the conventional surgical approach is to address only the affected metatarsal. With numerous options at the surgeon's disposal, the Weil and Schwartz osteotomies are popular surgical choices. It is estimated that 1:4 patients can have a sub-optimal outcome, following such surgery. Floating toes, joint stiffness, scar irritation, neuritis, and recurrence of the lesion may occur. Problems reported after the Weil osteotomy has prompted Dr. Weil to add the mini-scorpion to augment the repair.

Others, notably those engaged in minimally invasive surgery, advocate the 'Leventen formula', in combination with the MIS approach, in their attempt to provide for a superior outcome. There has been little, if any, debate about this topic.

What is the Leventen formula.

To provide for a better, more reliable and consistent outcome, following metatarsal osteotomy for central metatarsalgia, and to reduce the incidence of later additional surgery, Leventen devised a surgical approach to pre-emptively also address the adjacent metatarsals. This is based on the primary location.

For example, if the primary location affects the 2nd metatarsal (M2), both M2 & M3 will be addressed. If the primary lesion affects M2 & M3 (or M3 in isolation) the surgeon will adress M2, M3 & M4. If M4 is affected he will perform the osteotomies on M3 & M4.

Leventen's approach, which some now refer to as the 'Leventen Formula' , is named after Edward O. Leventen, MD. Dr. Leventen is an orthopedic surgeon. Leventen, in 1990, published a paper in the journal of Foot & Ankle, entitled 'Distal Metatarsal Osteotomy for Intractable plantar keratoses'.

Leventen observed that many patients would require additional surgery to manage the problem of new pain and transfer lesions, when surgical attention was confined to the site of the pathology. Leventen advocates for a particular strategy to know which of the metatarsals, in addition to the primary metatarsal, need to be addressed surgically, to both resolve the IPK and to limit also the risk of a possible transfer lesion to an adjacent metatarsal.

In this article, Leventen reports on the outcome of 21 feet, with an average follow up of 31 months. Outcome measures include a subjective assessment of pain & function. This is a non-validated outcome measure tool. (Not unusual for the year of publication). A clinical examination was performed for callus, stiffness, sensory changes, metatarsalgia. Harris mat impression was obtained and x-ray's performed.

Dr. Leventen performs conventional open surgery. Unlike the MIS surgeon, who perform an extracapsular through-and-through osteotomy, Dr. Leventen's technique is that of open surgery, a partial osteotomy (closing wedge-type configuration with manual osteoclasis w/out fixation) to elevate the metatarsal head, as modeled after the orthopedic surgeon, Wolf (1973). Wolf would confine his attention to the affected metatarsal only.

After the Leventen surgery 15 feet were rated good to excellent. 6 feet rated poor to fair. Clearly Leventen's reported outcome is far from perfect. The MIS surgeon contends the MIS technique used concurrently can improve on Leventen's results, and can provide for a better outcome, as compared to the contemporary surgical approach, currently in favor, obviating the need for adjunctive surgery, or additional technology.