Congenital Brachymetatarsia involving more than two metatarsals : One-stage combined shortening and lengthening procedure without iliac bone graft Moon Sang Chung, M.D., Goo Hyun Baek, M.D., Jin Sam Kim, M.D., and Pil Whan Yoon., M.D., Department of Orthopedic Surgery, Seoul National University College of Medicine

Congenital Brachymetatarsia Abnormal shortening of the metatarsal bone caused by premature closure of the epiphysis Female : Male = 98 : 4 Predominance in younger female patients → the goal of treatment focused on the good cosmetic results

Congenital Brachymetatarsia 72% of the cases being bilateral (Urano Y. et al, 1978) The fourth toe is most commonly involved, although any or multiple metatarsals may be affected

One-stage Lengthening vs. Gradual Lengthening 1. One-stage lengthening with intercallary bone graft Advantages - Shorter period of bony union - Lesser scar Disadvantages - Bone graft donor-site morbidity - Neurovascular impairment - Small length gain due to high tension

One-stage Lengthening vs. Gradual Lengthening 2. Gradual lengthening by callus distraction Advantages - No need for bone grafting - Easier tendon stretching - Lesser neurovascular complication - Early weight bearing Disadvantages - Joint stiffness, deformity - Pin site scar, Pin-tract infection - Longer period for bone consolidation - Ugly postoperative scar

Patients and Method Jan, 1994 ~ Dec, 2000 5 cases All female Bilateral involvement Congenital brachymetatarsia with 1st and one or two metatarsals Mean age : 15.8 (10 ~ 26) years Mean follow-up: 69.5 (29 ~ 107) months

Patients and Method Restoration of normal metatarsal parabola Length gain (mm) Percentage increase (%)

Patients and Method : equivalent to the time of solid bony union 4. Healing index (months/cm) : equivalent to the time of solid bony union Complications Satisfaction of the patient

Operative Procedures Modified one-stage combined lengthening and shortening technique A dorsal lazy S skin incision was made over second web space Two holes for wire fixation were made and 2nd and 3rd metatarsals were shortened

Operative Procedures One-stage lengthening technique of gradual distraction at operation The use of creep and stress relaxation for between 20 and 30 minutes No need for Z-plasty of the extensor tendon or V-Y plasty of skin No neurovascular problems The osteotomy site at the 4th metatarsal midshaft was gradually distracted by bone spreader

Operative Procedures The excisied bone was placed in the gap in the lengthened 4th metatarsal bone Wound was closed and sterile strip were applied

Results Good functional metatarsal parabola was restored. Mean length gain : 9.8 (5 to 12) mm Mean percentage increase : 28.3 (19 to 57) %

Results 4. Healing index : 2.0 (1.6 to 3.8) months/cm 5. No complications 6. All were satisfied with the cosmetic results and could walk on tiptoe and had no limitation in the activities of daily life.

Results Summary of the data of one-stage combined shortening and lengthening in 5 patients Patients Age Sex Involvement Shortening Lengthening Length gain (mm) Percentage increase (%) Healing Index (mo/cm) Case 1 14 F Both 1st , 4th Both 2nd,3rd MT Both 4th MT Rt : 11 Lt : 11 24% 2.1 Case 2 16 Both 1st , 4th , 5th Rt 4th MT Lt 4th PP Rt ; 9 Lt : 8 19% 57% 2.2 2.5 Case 3 10 Lt : 10 27% 23% 1.6 1.8 Case 4 13 Both 2nd,3rd MT 5th PP Both 4th MT, Both 4th PP Rt MT : 11 Lt MT : 11 Rt PP : 5 Lt PP : 8 22% 38% 1.7 3.8 2.4 Case 5 26 Rt : 12 21%

Case 1 (F/14) Before operation One year seven months after operation

Case (F/14) Before operation Immediately after operation One year seven months after operation

Case 2 (F/16) Before operation Nine years after operation Tip toeing

Discussion Modified one-stage combined lengthening and shortening technique Only one skin incision → Lesser scar Shorter length to restore normal parabola → Lower the risk of neurovascular complication

Discussion Modified one-stage combined lengthening and shortening technique Bilateral operation → Symmetrical feet Reduction feet size after operation

Conclusions Our modified one-stage combined lengthening and shortening technique may be a good treatment of choice to correct bilateral congenital brachymetatarsia. All patients were satisfied with their feet cosmetically and functionally without complications.