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I have a 49 y/o female with a prominent callosity lateral plantar 5th metatarsal head in which conservative treatment has been unsuccessful. Xrays do not show significant deformity of distal 5th metatarsal and soft tissue ultrasound was negative for underlying mass. Surgical intervention is being considered at this time, however, any thoughts would be appreciated on which surgical approach would be appropriate. Xrays are noted below.

 

Is that how it works?

I've got a patient who has a callus. Here's an X-ray that shows nothing unusual. How should I operate?

Is there not a lot of crucial information missing?

 

can I ask what conservative treatments have been used? have you performed a bio assessment? If so what did it show.

regards

ben

 

This patient was referred to me by another podiatrist for surgical evaluation and has exhausted conservative treatment with debridement, orthotics and shoegear modifications. Patient does have mild forefoot varus which is contributing to symptoms. I am very hesitant with surgical intervention, but wanted to get some thoughts on this case.

 

Is there equinus or difference in leg length?

 

Hi Jennrocky

Can you supply a little more background, especially around any similar swelling on the contalateral foot, social Hx and family Hx? Is there a chronic bursitis under the callus? Initial guess would be a tissue mass (obviously), maybe a fibroma with overlying skin lesion, but that is only a guess without more info.

All the best

Bill

 

Looks like the IM angle is increased. Do a Austin Tailor Bunionectomy for the best result.
Good luck
Teri
Teri Green
Atlas Biomechanics

 

How much eversion does the patient have of his forefoot? Have the patient stand and have her minimize movement of his knee and lower leg while she tries to lift up the lateral side of her forefoot. See if you can slide your finger under her lateral forefoot while she is standing in RCSP and looking straight ahead.

If you cannot, then she has no eversion ROM available of her forefoot and placing a forefoot valgus wedge will only overload her plantar 5th met and exacerbate her symptoms.

If she can lift up her lateral forefoot, then a 2-5 Forefoot valgus wedge using 3mm EVA/Korex can help her shift her weight from lateral to medial sooner during late midstance. This may help if she can wear appropriate shoes and after you debride the area.

You can also try a forefoot extension but pocket sub 5 with low rebound Poron for the plantar condyle to sit in, reducing the magnitude of force from GRF.

I would want to do work up the patient biomechanically before making a surgical decision. However, treating the radiographs, I would perform an oblique osteotomy to correct the deformity in both the transverse and sagittal plane. The osteomy is angled from dorsal proximal lateral to dorsal distal medial at the anatomical neck. Shift the capital fragment over medially and dorsiflex it about 2mm. Fixate with a buried K-wire. Ensure the lateral plantar aspect of the met head is rounded off. Patients wear a surgical shoe for 6 weeks and do very well. Transfer lesion to the 4th met is rare.

Steven