Mitchell, C. Leslie

VanHerpe, Leo

English

Henry Ford Health System Scholarly Commons

Henry Ford Hospital Medical Journal Volume 10 Number 1 Article 26 3-1962 Resection Of Metatarsal Heads For Painful And Intractable Plantar Callosities. A Report Of Ten Years Experience Leo VanHerpe C. Leslie Mitchell Follow this and additional works at: https://scholarlycommons.henryford.com/hfhmedjournal  Part of the Life Sciences Commons, Medical Specialties Commons, and the Public Health Commons Recommended Citation VanHerpe, Leo and Mitchell, C. Leslie (1962) "Resection Of Metatarsal Heads For Painful And Intractable Plantar Callosities. A Report Of Ten Years Experience," Henry Ford Hospital Medical Bulletin : Vol. 10 : No. 1 , 241-244. Available at: https://scholarlycommons.henryford.com/hfhmedjournal/vol10/iss1/26 This Part II is brought to you for free and open access by Henry Ford Health System Scholarly Commons. It has been accepted for inclusion in Henry Ford Hospital Medical Journal by an authorized editor of Henry Ford Health System Scholarly Commons. Henry Ford Hosp. ~led. Bull. Vol. 10, 1arch, pl. 2, 1962 RESECTION OF METATARSAL HEADS FOR PAINFUL AND INTRACTABLE PLANTAR CALLOSITIES. A REPORT OF TEN YEARS EXPERIENCE Leo VAN HLRPC , M.D. AND C. Lesuc Mirrnc1 L. l\-1 .D ~ 1ETATARSA I CIA i~ a common problem arising from different causes. It is hkel) to he ligh1ly considered by all excep1 1he vic1im "ho hobbles about as though he had a tack in his shoe. The multiplicity of procedures both operative and supportive designed for the a lleviation of symptoms attests to the difficulty in successfully treating this condition. The purpose of this paper is to re, iew the general problem of mclatarsalgia and the resu lts of trcatmcnl of th is cond11ion with metatarsal head resection. Mctatarsalgia by defin ition si mply refer!, to pain in the general area of the metatarsal heads of the foot. Of cour~e this is a common complaint in adults and in most cases ca n be dea lt with adequate ly by means of shoe correction~ and altera tion of the weight dis1ribution on the metatarsal heads. With improvement in shoe fitting and 1hc use of aids such as metatarsal pads, metatar!'lal bars, arch supports and paring of calluses, the majority of individua ls with 1his condition can be treated effectively. It is realized that pain in the forefoot may be the result of intcrdigital neuro-mata (Morton·s toe) , bursae and tumor beneath the metatar, .. ,1 heads and arthritis of the metatarsa l-phalangeal joints. However we are here concerned primarily "ith metatar aJgia associated with painful callosities under one or more of the metatarsal heads which have become resistant to conservative mea,ures. This may result from several causes: from a plantar wart under a met::uarsal head \\hich has not responded to the usual derma1o logical measures and which eventually presents as a healed plantar wart wi th a residual callus;1 from a pres~urc ca llus rc~uhing from disturbed metatarsal Y.eight distribution,' from a cavus foot with clawing of the toes or-A from residuals of meta larsa l-phalangeal arthritis with dorsa l dislocation of the proximal phalanx. on the metatarsal. Morton a ttempted to expla in the disturbed weight distr ibution on the basi~ of a short first metatarsal, hypcrmobility of the second metatar,al , and pronation of the foot.' Harris and Beath 5 in their meticulous study of 7,238 feet conclusively disproved this theory. It seems in cases involving disturbed Y.eight 1ransmis ion that ,omc fac to r has led to colbpse of the transvcr,c arch of the forefoo t allowing depression of the second, third and fourth met;.HJrsal heads. 241 VcmH l:.RPE A D MITCH/all When metatarsa lgia arises from the aforement ioned ca uses it usually presents a pic1ure of pain in 1he planlar aspec1 of the foot accompanied by lender planlar callosities usua lly located benea th the offendi ng meta tarsa l heads. Pain can be re-produced b) digi1al pressure on the ca ll us , by weigh1 bearing. plan1ar flexion of 1he toes , and frequent ly by lateral compression of the mctatars:1 1 heads. T he callosities are localed mos1 commonly benea1h 1he heads of 1he second, 1hird, and / or fo un h metatarsals. They arc more common in women and more likely to occur after the fo urth decade. Planta r ca llosities are li kely to become intractable and become re-garded as plantar warts; however, as DuVriesl point out. it is questionable whether the c arc 1ruc verrucae. More commonly they represent ca ll us formation in respo nse to pressure or cica1rix form ations secondary to local treat ment. True plantar warts may occur al any place on lhe planiar surface of 1he fool. They are usua lly found anteriorly 10 the weight betHi ng areas and can be readily identified by their vascu lar center core which bleeds on paring. Many procedu res have been devised to dea l with merntarsalgia associa ted with painrul intractable plantar callosities. Dermatologists have some success using electro· dessication , cautery, radiation, o r chemical agents. In many cases this approach is apparently successfu l but in some it is not , and usually adds to the size and persislcnce of the call us. Ahhough paring 1he callu es provides 1emporary refief ii, like e...:cision of the area, affords no lasting cure even when excision is combined wi th skin grarting. Contrast thi~ with the radica l approach advocated by Dickson' who excises the involved ray, toe, metatarsa l, and plantar ca llosi ty in refrnctory cases. Other procedure of less magnitude are available and perhaps more applicable si nce Dickson's operation is best confined to a single ray, whereas this condition is freq uently multiple. Giannes1ras• has devised a metatarsa l shortening consisting of ostcotomy of the invo lved meta tarsa l in a step·cut fas hion providing the necessary recession of the prc~sure poi nt. T his operation, like any o teomy, has the d isadvantage o f re· tric1ed activity in a cast until the completion of bone union. DuVries3 describes an approach based on removing 1he spike-l ike condylar processes which pro1rude into the sole wit h depression of the metata rsa l head. While condylecto my seems ra tional o ur experience wit h this procedure is limited. Direct atl ack o n the offending metarn rsal head is 1he goal of 1wo 01her procedu res. T hal described by Mc Keever' 6 is accom-plished by hollo" ing ou1 1he me1a1arsal head and replaci ng it o n the poinled metalarsal shaf1. T he most di rect approach is simply resec1ion of the o ffend ing me1a1arsal head or heads. The lauer procedure is 1he one employed al Henry Ford Hospilal for this condi tion. This paper presents a review o r the results of metatarsal head resec tion for painful in1rac1able planiar callosi1ies. In 1he period from January 1950 10 July 1960, 52 pa1ien1s had a 101al f 85 me1a1arsa l heads resected. The second melalarsa l head was most commonly in,olved comprising 48.2 percent of those re cc1ed. As sum· marized in Table I, the 1h ird, fourlh and fif1h fo llowed in 1hat o rder showing equal dis1r1bution 10 1he righ1 and lefl feet. Indica tions for resect ion were mcrntarsa lgia associated with painful intractable plantar callos11ies refractory to conc;ervative treatment in 45 patients or 86 per cent. Rheumatoid foo t problems accounted for 8 % ;tnd miscellaneous causes for 6 per cent. 242 RESECTION OF METATARSAL HEADS Table I lle Ad Number Right Foot Left Foot 21 24.7% 20 23.S % ll 15.0% 14 16.0'c 5 6.0 t'.c 6 7.0'1: l .5% J 3.5~ Total 48.2'1-ll.O'l> 13.0'1: 7.0% There was a prepcnderancc of females in the seric : 33 or 61.5 per cent of the total. The average age of the group was 47.9 years tending to be older (51.3 years) for the women and younger (44.5 years) for the men. The duration of symptoms prior to urgcry tended to be long, averaging 9.6 years. Most patients had been treated with multiple shoe aids during this time. To evaluate accurately the results of this procedure which sometimes was done in association with other foot surgery, a personal examination was desirable. Of the original group 34 people responded and 28 presented for examination . The remaining six due to distance answered a detailed questionnaire regarding their case. Of this group, six were discarded as their symptoms were either due to rheumatoid changes or trauma. The remaining 28, having a total of 45 head re ections, were analyzed for this follow-up study. An arbitrary rating was set up as follows: EXCELLENT .Long follow-up with no symptoms relative to original condition or resulting from surgery. GOOD .Long follow-up with improvement maintained and minimal new symptoms. FA IR . .Condition improved by operation but new symptoms bothersome. POOR . . . . . . .Operation no help or new symptoms as bad or worse than original. Using these criteria the results of resec1ion were analyzed for each metatarsal head and showed no significant difference in satisfactory results regardless of which head was rcsected. The recurrence rate for the whole group was a disappoinling 50 per cent (Table II). Table II RESULTS BY HEAD R ECTED -Number Excellent Good Fair Poor 2 6 J 4 7 J 5 1 2 7 4 J I 0 4 5 t t 0 0 Analysis on the basis of the patient's age, duration of symptoms prior to surgery, or multiple versus single resections failed to show any significant correlation with resulls. The x-rays were also reviewed attempting to anticipate the result from comparison of the deformity with the surgical correction with no conclusive findings. From the standpoint of sex, it was interesting to note that most of lhe males had 243 Va11HcRP£ AND MITCHELL a good or excellent resull (eight or nine or 90 per cent) . whereas a preponderance or the fem ales had a fair or poor re ult (23 or 36 or 64 % ) (Table Ill ). Su Male Female El(ccllcnt JO Table III Fair Poor 17 The follow-up period ranged from one 10 eigh1 years with the group averaging 4.0 )Cars. The two most frequently cncoun1ercd undesirable results of this operation were shifl of the pressure point from one metatarsa l head to the adjacent o ne or more head accounting for most of the poor results in the series. and retraction of the operated toe dorsally on the foot in a position 10 incur dorsal clavus formation. We reel Jhis latJer problem can be obviated by doing an ex1ensor tenotomy and removing a segment of the tendon to discourage regeneration at the time of surgery. In several case having a paor result from the original surgery a second metatarsal head resection was done when the locus of pain had transferred to an adjacent head. The second procedure foiled to alter the final rating in these cases. We believe the greater number or successfu l results in the males is significant and probably reflec ts the greater tendency for women to wear unsa1isfactory footwear regardle s or discomfort. Certain ly wearing high heel shoes causes a shi rt of weight 10 the metatarsal heads. arrow lasts cause crowding or the forefoot and a fairly high incidence or hallux valgus which has been frequen1ly rela ted 10 second ray metata rsa lgia. 11 was noted 1hat pa11en1S having mulliple foot problems were less likely to have a saJi sfacto ry resuh from metatarsal head resection even when done in association with ot her procedures to ccrrect those deformities. It "'as our hope in undertaking this sludy that criteria for a uccessful opcra1ion could be established 10 increase 1he percentage or favorable results. This hope has not been realized. We are left with a procedure on ly 50 per cent effc1ive in un-selected cases regardless of which head is involved and more than twice as likely to be a success in males than in females. It does not seem to be as good an operation as was originally thought, though in specific cases it may give very sa tisfactory results . REFEREN ES ampbcll . W. .: O~rative Orthopaedic . ed. by J. . Speed and R. A. Knight , ed. 3, St. Louis. Mo<by, 1956. v. 2. pp. 1913-78. R1 chson, J . A.: Surgical 1rcatment of intrnctnble plantur w:ms, J. Bone & Joint Surg. 30A :757, 1948 . 3. DuVnes. II. L. : New approach to 1rcn1mcnt or m1rnc1able verruca plan1nris, J. A. M. A. 1~2'1202. 1951 4 G1anne'itr1S, J.: Shortening of the metatarsal shaft for corre tion or planlar ker:nosis , Clin. ~ 11am ~r~hoF.', ~=;J5iJ!:~:.· T.: The short firs! mc1atarsal ; its incidence and clin ica l significance, MtKc! ... ~~neD& Jo.ml ~u:i\\r~J:~ti!f 1~~:· firs1 mc1a1arso-phalnngcal vnlgus, hallux rigidus and 7. \lih:h~~ta~ai"'t p~~s ~r'b;S:~ Bo:~l 1~%~!cs~u~ta?~:~1~2: · :J.5~ .• Bunerv.·orth , Inc., 1960, pp 49-52. ti ~hand,, ·\ R llandbool of Orthopaedic Surgery, ed. S. St. Louis, Mosby. 1957, pp. 536-41. 9 Mo rton, D J The Human Foot, Nev. York , Columbia Un1\'crsi1y Press, 1935. 244 

Resection Of Metatarsal Heads For Painful And Intractable Plantar Callosities. A Report Of Ten Years Experience

https://scholarlycommons.henryford.com/cgi/viewcontent.cgi?article=3103&amp;context=hfhmedjournal

Resection Of Metatarsal Heads For Painful And Intractable Plantar Callosities. A Report Of Ten Years Experience

Abstract

Similar works

Full text

Available Versions

Henry Ford Health System Scholarly Commons