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Lesser metatarsal surgery

Metatarsalgia:  This is a general term covering pain in the ball of your foot. 

The causes of this are many including bone, joint, soft tissue and skin problems.  You have been diagnosed with a bone or joint condition. The symptoms include, throbbing pain, swelling, the feeling of walking on a lump or pebble and sometimes hard skin or a corn under the affected joint.  The problem is often worse in thin sole or high-heel shoes, and aggravated by standing for long periods or lengthy walks.  Sometimes the adjacent toes splay, become deformed, or start to float upwards. The cause is overloading of the metatarsal head. 

The diagnosis is normally made following a review of the history, clinical examination, investigations including X-ray, MRI and ultra sound scanning. Sometimes diagnostic injections of local anaesthetic are used to numb the joints and help determine the exact location of the symptoms.

Treatment options

Conservative care

There are several treatments that may reduce or relieve your symptoms:

• The right footwear for the right occasion.  Shoes need to be of the correct length with a fastening. The shoe would preferably have a stiff sole and a toe spring e.g. walking shoes or MBT.
• Palliative treatment to reduce hard skin
• Insoles or orthoses.
• Cortisone injections in conjunction with the above treatments or immobilisation
• Anti inflammatory medication

Surgical treatment

The common surgical management for this condition is an osteotomy of the lesser metatarsal(s) if conservative cares fails to be effective. This operation will shorten with or without elevation of the bone(s).  The aim is to provide an equal distribution of weight across the forefoot, with a corresponding reduction in the pain under your foot.

An incision is made on the top of the foot.  The metatarsal is cut, re-aligned, and secured in a corrected position with a screw.  An absorbable suture is used to close the skin.  The operation takes between 30 minutes.

The patient had pain beneath the central metatarsal heads due to a short first metatarsal.  Consequently the 2nd, 3rd and 4th metatarsals have been shortened to provide an even distribution of weight beneath the forefoot. 

Tailors bunion

Here the fifth metatarsal head is prominent and therefore prone to irritation from shoes. In cricumstances where this prominence cannot be accomodated by your shoes the deformity can be realigned.

This patient had a prominent bunion on both the inside and outside of the foot.  These have been corrected by osteotomies along with straightening of the 2nd and 3rd toes. 

Day surgery
You would be admitted to the hospital on the day of your operation.  Professor Tagoe will mark the surgical site(s) and confirm your consent. Dr Nathwani (anaesthetist) will visit you to discuss your anaesthesia.

Anaesthesia

Most patients elect to have their operation carried out under local anaesthetic with sedation, under the care of Dr Nathwani Consultant Anaesthetist.

Sedation

There are different depths of anaesthesia from sedation through to a general anaesthetic.  Sedation provides reduced consciousness with most of your reflexes left intact and spontaneous breathing. This means that your airway is secure and there is no need to place a tube into your throat. As well as sedation a local anaesthetic block at the level of the ankle is performed to render the surgical area anaesthetised. This allows us to keep the amount of drugs used to a minimum.  The sedation wears off within a few minutes of the end of the operation, without the accompanying drowsiness and nausea, which is sometimes associated with general anaesthesia. The operation is pain free and patients remember nothing of the surgical experience.

Local Anaesthesia

Professor Tagoe will anaesthetise your leg via an injection in the back of your knee (popliteal block).

As the anatomy behind the knee varies a little from person to person we use a nerve stimulator to locate the nerves. This sends a small electric current down the needle which stimulates the nerve. This means that the muscles controlled by the nerve begin to contract and relax causing the foot to ‘flick’. Whilst this is a strange sensation, it is not uncomfortable and helps us to deliver the anaesthetic with precision.

Local anaesthetic at the level of the knee not only blocks sensation but also movement of your foot.  This is temporary lasting for 24 to 36 hours and has the advantage of providing long lasting pain relief and numbness. 

Discharge

Before you leave the hospital you will be given a post operative shoe and shown how to partially weight bear on the foot using crutches.  Post operative painkillers will be dispensed by the nurse. 

You should arrange to go home via car or taxi with an escort.  You are advised to have someone with you for the first twenty four hours in case you feel unwell.
 
Recovery

You must rest with the leg elevated for the first 48hrs (essential walking only). It is important that you do not interfere with the dressings and keep them dry.  You can buy a purpose made waterproof cover to keep the leg dry from your local pharmacy. Professor Tagoe will see you for a dressing change 3-4 days post surgery, most patients can then return to walking to tolerance around the house.  You will be seen by the nurse 10 days following the surgery when the dressing will be removed and the suture tags cut.  Range of motion exercises for the joint will be started and you can return to a trainer.  From this point on you can wash your foot.  A gradual increase of low impact activities is possible. No hopping, skipping or jumping for the first 8 weeks as it takes this length of time for the 2 bones to heal. Once out of the post operative shoe you can drive your car as and when you feel safe.

It is normally six or seven months before patients have fully recovered.  Swelling and an ache around the surgical site are common during this period.

Physiotherapy
This is instigated 10 days post surgery depending on how well you are progressing. The use of the Darco Toe Alignment Splint at night helps prevent the toes from becoming elevated.

Audited results for this operation:

Audit of patient’s pre and post surgery is routinely carried out within this department.  A 100 point clinical rating system is used to assess pain, function and alignment, a score of 100 being perfect.  The average pre-operative score was 40.7, following the surgery the average outcome was 85.22.  29% of patients noticed that their toe(s) following the surgery did not grip the ground, as well as that prior to the operation.

Possible complications

Approximately 900 patients undergo foot surgery annually within the Department of Podiatric Surgery at West Middlesex University Hospital.  Most patients have an uneventful recovery.  Outlined below are the common problems or those rare complications with serious outcomes.  In cases where we don’t have accurate audit, we have used published results from the podiatric literature.  These are accompanied by an asterisk *

• Prolonged swelling taking more than 6 months to resolve occurs 1 in every 500 operations*
• Haematoma – a painful accumulation of blood within the operation site. No recorded incidents.
• Thick and or sensitive scar – no audit data is available.
• Screws and plates were removed from 118 patients during a twelve month period.  This is often planned but can occur as a result of irritation. 
• Adverse reaction to the post operative pain killers.  1 in every 50 patients report that the codeine preparations can make them feel sick.*
• Infection of soft tissue.  The incidence is 1 in every 83 operations*
• Infection of bone occurred in 3 out of 916 patients.
• Delayed healing of soft tissue or bone.  No audit data is available.
• Circulatory impairment with tissue loss occurred in 3 out of 9000 patients over a 10 year period.
• Loss of sensation can occur although this is usually transient but can take up to a year to resolve.
• Deep vein thrombosis which can result in a clot in the lung is potentially a life threatening condition.  Deep vein thrombosis incidence is 1 in every 900 cases.
• Chronic pain syndrome: this is where the nervous system dealing with pain over reacts in a prolonged manner often to a minor incident.  This normally requires management by specialists in this condition and doesn’t always resolve.  This is a rare complication with no audit data available.
• Reoccurrence of the deformity or failure of the operation: incidence is 1 in every 500 operations.*
• Development of secondary problems including overloading of joints adjacent to the ones operated on occurs in 1 in every 700 operations.*

Specific complications following lesser metatarsal surgery:

• Transfer of pain or skin lesion to an adjacent metatarsal head
• Floating toe.
• Joint stiffness
• Scar contracture
• Fracture
• Non-union of bone
• Continued pain
• A lumpy scar tissue, this normally resolves with post-operative massage or physiotherapy

The risk of having a complication can be minimised when the patient and all those concerned with the operation and aftercare work together. This starts with the pre-operative screening and continues through to the rehabilitation exercises.

Pre operative screening of your health allows us to determine whether you are fit for surgery.  It is important that you disclose your full medical history.  If there is a query regarding your health, then further investigations or the advice of other surgical and medical specialties will be sought. The surgeon and the theatre team will ensure that the operation is performed effectively and with the minimum of trauma.

You can improve the healing process and reduce the risks of complications by:

• Adhering to the post operative instructions which include resting and elevating the operated leg.  Keeping the wound clean and dry until advised otherwise is essential.  Please ask the nurses or the team if you are not sure what to do.
• Having a healthy diet is important; this provides the nutrition required for healing.
• Smoking is associated with a 20% increased risk of delayed or non healing of bones.
• Alcohol can interact with the drugs that we will prescribe and in excess can impair wound healing.
• Post-operative mobilisation will be advised, this helps improve the flexibility, strength and stability of your foot.

Podiatric surgeons evaluate, diagnose, prevent and treat diseases, disorders and conditions affecting the foot and all associated structures.  This is carried out in keeping with the individuals, education, training and experience, in accordance with the ethics of the profession and applicable law. 
 

Podiatric Surgical Training
3 year:	Degree in Podiatry
2 year:	General Podiatric Practice
2 year:	Diploma in the theory of podiatric surgery
2 Year	Surgical training programme (Podiatric Surgical Trainee)
	Final fellowship examinations
3 year:	Specialist training (Podiatric Registrar)
Accreditation with the Faculty of Podiatric Surgery Consultant Podiatric Surgeon

Secretaries:

Marina Nichols:
08700 410 448
Email: marina@thetagoeclinic.co.uk