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Recurrent plantar ulceration following pan metatarsal head resection
Recurrent Plantar Ulceration Following Pan Metatarsal Head Resection Although the pan metatarsal head resection, since it was originally described and performed by Hoffman in 1911, has proven to be an effective and viable procedure in treating many forefoot deformities, it is not without its own complications. The authors provide an historical perspective of the pan metatarsal head resection, a discussion on the complication of recurrent plantar ulceration after the pan metatarsal head resection, and a review of their own experience with this procedure. A retrospective review was performed of all patients having undergone pan metatarsal resections between August 1980 and Apri/1993. Twenty procedures were performed on 12 patients with diabetic neuropathy, and 21 procedures were performed on 15 patients with rheumatoid arthritis. The incidence of recurrent plantar ulceration after surgical correction was 25% and 28%, respectively. All 27 patients underwent primary healing. The authors, therefore, conclude that the complication of recurrent plantar ulceration after this procedure is a very likely and distinct possibility. (The Journal of Foot and Ankle Surgery 35(6):573-577, 1996) Key words: pan metatarsal, head resection, ulceration
Oleg Petrov, DPM, FACFAS1 Mark Pfeifer, DPM2 ,3 Michael Flood, DPM 2
William Chagares, DPM 4 Christopher Daniele, DPM 5
The pan metatarsal head resection was originally devised for relief of pain and deformity in patients suffering from rheumatoid arthritis. The procedure was initially described by Hoffman in 1911 (1). Hoffman's original procedure consisted of excision of all the metatarsal heads and, when deemed necessary, a portion of the metatarsal neck. The procedure was performed through a single transverse plantar incision, placed immediately proximal to the web of the toes. Clayton later performed this procedure using a dorsal transverse incision, proximal to the bases of the digits. He also removed a portion of the proximal phalangeal bases (2). Kates, Kessel, and Kay further modified the original procedure (3). It was performed through a transverse incision that was convex and proximal to the metatarsal neck level. They then excised an ellipse of skin, approximately 1 inch in width at its center and extending in a medial to lateral direction across the plantar pedal
surface (3). Larmon described the three dorsal linear incision approach (4). In 1983, Hodar and Dobbs described the use of five dorsal incisions to accomplish the pan metatarsal head resection (5).
From the Veterans Affairs Medical Center, North Chicago, Illinois. Presented at the 1994 American College of Foot and Ankle Surgeon's 52nd Annual Meeting and Scientific Seminar. 1 Director of Podiatric Medical Education. Address correspondence to: 111 North Wabash Avenue, Suite 1914, Chicago, IL 602022002. 2 Submitted while podiatric resident. 3 Fellow, American College of Podiatric Radiology. 4 Chief, Podiatry Service. S Attending staff, North Chicago Veteran's Affairs Medical Clinic. The Journal of Foot and Ankle Surgery 1067-2516/96/3506-0573$3.00/0 Copyright © 1996 by the American College of Foot and Ankle Surgeons
Methods
A retrospective chart review of 27 patients who underwent solely pan metatarsal head resection between August 1980 and April 1993 was performed. All patients were in one of two categories: those who suffered from severe debilitating rheumatoid arthritis, and those who suffered from chronic neuropathic ulcerations that failed to respond to conservative treatment. Local debridement, wet-to-dry sterile gauze dressing changes twice a day, various types of wound-healing agents, accommodative padding, shoe modifications, nonweightbearing felt dressings, and orthoses were used before surgical intervention. Excluded from this review were patients who had metatarsal heads resected as isolated procedures. Appropriate administration of intravenous antibiotics was started, as determined from wound cultures, and maintained until hospital discharge. Appropriate oral antibiotics were then provided. When necrotic and/or infected tissue was replaced with healthy granulation tissue, the patient was then considered a candidate for surgery. The rheumatic patients were considered as candidates based on the debilitating nature of their disease. It was determined that surgery was an alternative only VOLUME 35, NUMBER 6, 1996
573
TABLE 1 Patient
2 3 4 5 6 7 8
9 10 11 12
Clinical information/diabetic patients Foot
Sex
Date
Right Left Right Right Left Right Left Left Left Right Right Left Right Left Right Left Left Right Left Left
M
8/80 11/81 10/80 9183 5/84 2/84 4/86 8/84 4/85 11/88 5185 11/85 2/87 11/87 1190 4/95 12/91 1192 4/92 6/92
F M F M F F M M M F F
Months Prior to Ulcer Recurrence
Location of Recurrence
84 78 0 0 0
sub 4th MT sub 3rd MT
54
sub 4th MT
0 104 0 0 0 0 0 0 6 0 0 0 0 0
sub 3rd MT
sub 1 & 5 MT
Total Number of Months
Number of Years Diabet ic
160 145 157 123 115 118 92 112 104 61 103 97 82 73 48 12 24 23 20 18
17 12 14 10 9 6 10 7 20 22 31 15
Totals: Right = 9 Left = 11 Male = 6 Female = 6 M = male F = female MT = metatarsal
when all conservative approaches to controlling symptoms of pain and attempts at healing patients' ulcerations had been exhausted, such as nonsteroidal antiinflammatory therapy, custom-molded shoe gear, and multiple physical therapy devices. Operative Techniques
These authors preferred the three dorsal linear incision surgical approach for all 41 procedures. The major advantage of this approach was a reduced amount of soft tissue closure, which is required with this technique. After adequate intravenous sedation, aseptic preparation, draping and inflation of tourniquet when indicated by preoperative assessment of the vascular status, and consideration of history of thrombophlebitis, three linear incisions were placed directly over the first metatarsophalangeal joint (MPJ) , between the second and third metatarsals, and between the fourth and fifth metatarsals. The surgical incisions were deepened to the joint capsules, preserving all vital neurovascular structures. Extreme care was taken to avoid tenotomizing the long extensor tendons. After the capsular tissue had been resected from the MPJs, the collateral ligaments were resected and metatarsal heads freed of all plantar attachments. The meta574
tarsal heads were then removed at the surgical necks. The metatarsal parabola should be maintained after metatarsal head resection, so as not to create new areas of increased pressure that may also lead to ulcerations postoperatively. Closure of the dorsal wounds was performed in layers (deep to superficial) with suture material of the surgeon's choice. Postoperative treatment consisted of complete bed rest for 2 to 3 days, elevation of the operated extremity, appropriate antibiotic therapy, pain medications as needed, and initial nonweightbearing with crutches for the first 2 to 3 weeks. Sutures were removed at 2 to 3 weeks. Patients then progressed to complete weightbearing, with wooden-soled surgical shoes and advancing to full weightbearing in normal shoe gear. Results
Between August 1980 and April 1993, 27 patients underwent pan metatarsal head resections as previously described. There were 16 males and 11 females. The average patient age was 60.6 years, with a range of 43 to 80 years. Patients suffered from either diabetes or rheumatoid arthritis. Average duration of diabetes was 14.8 years, with a range of from 7 to 31 years (Table 1).
THE JOURNAL OF FOOT AND ANKLE SURGERY
TABLE 2
Clinical information/rheumatoid patients
Patient
2 3 4 5 6 7 8 9 10 11 12 13 14 15
Foot
Sex
Date
Left Right Left Right Right Left Right Left Right Right Left Right Right Right Left Left Left Right Left Right Right
F
3/82 7/82 3/82 5/83 6/83 12/85 10/86 9/88 6/89 3/89 3/89 2/92 6/89
F M F F F M M M M M M M M M
2190 4/90 4/90 4/91 8/92 3/93 5/91
2193
Months Prior to Ulcer Recurrence
location of Recurrence
Total Number of Months
62 0 0 0 97 69 42 0 38 0 0 0 18 0 0 0 0 0 0 0 0
sub 2nd MT
143 139 141 127 126 96 86 63 54 56 55 22 54 46 44 44 32 16 9 31 11
sub sub sub sub
2nd MT 2nd MT 2nd MT 3rd MT
sub 2nd MT
Number of Years Rheumatoid
6 8 20 19 19 8 19 10 3 10 5 8 14 13 2
Totals: Right = 12 Left = 9 Male = 10 Female = 5 F = female M = male MT = metatarsal
Average duration of rheumatoid arthritis was 10.9years, with a range of from 2 to 20 years (Table 2). Forty-one procedures were performed and evaluated retrospectively. Thirteen patients had pan metatarsal procedures performed bilaterally. One patient had contralateral pan metatarsal surgery 3 years after the initial pan metatarsal procedure. The results from 41 procedures were evaluated for recurrence rate of ulceration after pan metatarsal head resection. The average length of follow-up was 6 years and 2 months, with a range from 9 months to 13 years and 4 months. Primary healing was achieved in all 41 procedures. There were seven postoperative complications in the 27 patients. Three patients suffered early wound dehiscence of the lateral incision and were treated unevent-
fully. Two patients suffered from an early postoperative infection that was eradicated with appropriate antibiotic therapy. Another patient suffered from early hematoma formation, which resolved uneventfully. The most serious complication that occurred was a deep venous thrombosis. This was treated with appropriate heparin therapy and the patient was subsequently discharged from the hospital on coumadin. Eleven of the twenty-seven patients reulcerated. The average length of time for reulceration to occur was 4 years and 5 months, with the earliest reulceration at 6 months. The most delayed reulceration occurred 8 years and 8 months postoperatively. Eleven of the forty-one procedures reulcerated. This represented an average 27% recurTABLE 4
TABLE 3
Frequency of ulcer recurrence in diabetics
Frequency of ulcer recurrence in rheumatoid patients
Metatarsal Head
Percentage
Metatarsal Head
Percentage
First Second Third Fourth Fifth
16.50% 0% 33.50% 33.50% 16.50%
First Second Third Fourth Fifth
16.6% 50.00% 16.7% 0% 16.7%
VOLUME 35, NUMBER 6, 1996
575
FIGURE 2 Gross specimens of regeneration of metatarsal heads 2 through 5.
FIGURE 1 Roentgenographic illustration demonstrating osseous metatarsal regeneration after pan metatarsal surgery.
renee rate. The most frequent location of recurrence was the second metatarsal (41.6%) (Tables 3, 4). Discussion
There may be a number of reasons why a patient reulcerates after pan metatarsal head resection. For example, exacerbation of peripheral vascular disease; progression of a systemic condition such as diabetes mellitus or rheumatoid arthritis; poor control of diabetes postoperatively, or possible change in the normal weightbearing parabola of the foot secondary to the procedure itself, resulting in increased pressure areas on the plantar aspect of the foot, which may lead to reulceration. The authors, in their own experience, found that the most common etiological factor leading to reulceration was boney regeneration of the metatarsal heads (Fig. 1). This was initially determined by roentgenographic comparison of old versus recent films, and, secondly, through histopathological examination after revisional surgery. Radiographically, it appeared as if the metatarsal heads regenerated, either partially or fully. 576
FIGURE 3 Gross specimen of complete regeneration of a third metatarsal head.
Gross histopathological studies revealed boney regrowth of the metatarsal heads (Figs. 2-4). Microhisto pathological studies revealed new bone growth by the presence of many active osteoblasts in the marrow cavities (Fig. 5). The presence of the irregular nature of the cement lines versus the concentric nature of these lines, as is seen in old bone, is also indicative of new bone formation (Fig. 5). Dorland's Medical Dictionary" defines cement lines as a name applied to a line, visible in microscopic examination of bone in cross section, marking the boundary of an osteon (haversian system). Finally, the fact that very few osteocytes are seen, which are normally present in increased numbers in old bone, suggests this is regenerating bone formation (Fig. 6).
6 Dorland's Illustrated Medical Dictionary. 28th ed., p. 942, W. B. Saunders, Co., Philadelphia, PA, 1994.
THE JOURNAL OF FOOT AND ANKLE SURGERY
FIGURE 4 Gross specimen showing regeneration of a fifth metatarsal head.
FIGURE 8 A, Zone of fibrocartilage. B, Zone of fibrous connective tissue. C, Zone of regenerating bone with a few osteoclasts, increased fat cells, and osteoblastic activity signifying bone regeneration.
References
FIGURE 5 A, Active osteoblastic activity in regenerating bone. B, Fat cells. C, Irregular shape of the cement lines.
1. Hoffman, P. An operation for severe grades of contracted or clawed toes. Amer. J. Orthop. Surg. 9:441-448, 1911. 2. Clayton, M. L. Surgical treatment of the rheumatoid foot. In Foot Disorders, edited by Giannestras, N. J., pp. 319-340, Lea and Febiger, Philadelphia, 1967. 3. Kates, A, Kessel, L., Kay, A Arthroplasty of the forefoot. J. Bone Joint Surg. 49B:552-557, 1967. 4. Larmon, W. A Surgical treatment of deformities of rheumatoid arthritis of the forefoot and toes. Bull. Northwestern. Univ. Med. Sch. 25:39-42, 1951. 5. Hodor, L., Dobbs, B. Pan metatarsal head resection. J. Am. Podiatr. Assoc. 73:287-292, 1983. 6. Hugar, D. W., Gucfa, C. P. Pan metatarsal head resections: the Hoffman procedure. J. Am. Podiatr. Assoc. 64:983-986, 1977.
Conclusion
Although pan metatarsal head resection has been an accepted and effective procedure for the management of both the painful, arthritic foot and the neuropathic foot, it is not without complications. The main problem is metatarsal head regeneration, ultimately resulting in reulceration. The podiatric surgeon should be aware of this complication as a potential postoperative occurrence.
Additional References Giurini, J. M., Basile, P., Chrzan, J. S. Pan metatarsal head resection: a viable alternative to the transmetatarsal amputation. J. Am. Podiatr. Med. Assoc. 83:101-107, 1993. Giurini, J. M., Habershaw, G. Pan metatarsal head resection in chronic neuropathic ulceration. J. Foot Surg. 26:249-252, 1987. Tillo, T. H., Giurini, J. M., Habershaw, G. M. Review of metatarsal osteotomies for the treatment of neuropathic ulcerations. J. Am. Podiatr. Med. Assoc. 80:211-217, 1990.
VOLUME 35, NUMBER 6, 1996
577
Oleg Petrov, DPM, FACFAS1 Mark Pfeifer, DPM2 ,3 Michael Flood, DPM 2
William Chagares, DPM 4 Christopher Daniele, DPM 5
The pan metatarsal head resection was originally devised for relief of pain and deformity in patients suffering from rheumatoid arthritis. The procedure was initially described by Hoffman in 1911 (1). Hoffman's original procedure consisted of excision of all the metatarsal heads and, when deemed necessary, a portion of the metatarsal neck. The procedure was performed through a single transverse plantar incision, placed immediately proximal to the web of the toes. Clayton later performed this procedure using a dorsal transverse incision, proximal to the bases of the digits. He also removed a portion of the proximal phalangeal bases (2). Kates, Kessel, and Kay further modified the original procedure (3). It was performed through a transverse incision that was convex and proximal to the metatarsal neck level. They then excised an ellipse of skin, approximately 1 inch in width at its center and extending in a medial to lateral direction across the plantar pedal
surface (3). Larmon described the three dorsal linear incision approach (4). In 1983, Hodar and Dobbs described the use of five dorsal incisions to accomplish the pan metatarsal head resection (5).
From the Veterans Affairs Medical Center, North Chicago, Illinois. Presented at the 1994 American College of Foot and Ankle Surgeon's 52nd Annual Meeting and Scientific Seminar. 1 Director of Podiatric Medical Education. Address correspondence to: 111 North Wabash Avenue, Suite 1914, Chicago, IL 602022002. 2 Submitted while podiatric resident. 3 Fellow, American College of Podiatric Radiology. 4 Chief, Podiatry Service. S Attending staff, North Chicago Veteran's Affairs Medical Clinic. The Journal of Foot and Ankle Surgery 1067-2516/96/3506-0573$3.00/0 Copyright © 1996 by the American College of Foot and Ankle Surgeons
Methods
A retrospective chart review of 27 patients who underwent solely pan metatarsal head resection between August 1980 and April 1993 was performed. All patients were in one of two categories: those who suffered from severe debilitating rheumatoid arthritis, and those who suffered from chronic neuropathic ulcerations that failed to respond to conservative treatment. Local debridement, wet-to-dry sterile gauze dressing changes twice a day, various types of wound-healing agents, accommodative padding, shoe modifications, nonweightbearing felt dressings, and orthoses were used before surgical intervention. Excluded from this review were patients who had metatarsal heads resected as isolated procedures. Appropriate administration of intravenous antibiotics was started, as determined from wound cultures, and maintained until hospital discharge. Appropriate oral antibiotics were then provided. When necrotic and/or infected tissue was replaced with healthy granulation tissue, the patient was then considered a candidate for surgery. The rheumatic patients were considered as candidates based on the debilitating nature of their disease. It was determined that surgery was an alternative only VOLUME 35, NUMBER 6, 1996
573
TABLE 1 Patient
2 3 4 5 6 7 8
9 10 11 12
Clinical information/diabetic patients Foot
Sex
Date
Right Left Right Right Left Right Left Left Left Right Right Left Right Left Right Left Left Right Left Left
M
8/80 11/81 10/80 9183 5/84 2/84 4/86 8/84 4/85 11/88 5185 11/85 2/87 11/87 1190 4/95 12/91 1192 4/92 6/92
F M F M F F M M M F F
Months Prior to Ulcer Recurrence
Location of Recurrence
84 78 0 0 0
sub 4th MT sub 3rd MT
54
sub 4th MT
0 104 0 0 0 0 0 0 6 0 0 0 0 0
sub 3rd MT
sub 1 & 5 MT
Total Number of Months
Number of Years Diabet ic
160 145 157 123 115 118 92 112 104 61 103 97 82 73 48 12 24 23 20 18
17 12 14 10 9 6 10 7 20 22 31 15
Totals: Right = 9 Left = 11 Male = 6 Female = 6 M = male F = female MT = metatarsal
when all conservative approaches to controlling symptoms of pain and attempts at healing patients' ulcerations had been exhausted, such as nonsteroidal antiinflammatory therapy, custom-molded shoe gear, and multiple physical therapy devices. Operative Techniques
These authors preferred the three dorsal linear incision surgical approach for all 41 procedures. The major advantage of this approach was a reduced amount of soft tissue closure, which is required with this technique. After adequate intravenous sedation, aseptic preparation, draping and inflation of tourniquet when indicated by preoperative assessment of the vascular status, and consideration of history of thrombophlebitis, three linear incisions were placed directly over the first metatarsophalangeal joint (MPJ) , between the second and third metatarsals, and between the fourth and fifth metatarsals. The surgical incisions were deepened to the joint capsules, preserving all vital neurovascular structures. Extreme care was taken to avoid tenotomizing the long extensor tendons. After the capsular tissue had been resected from the MPJs, the collateral ligaments were resected and metatarsal heads freed of all plantar attachments. The meta574
tarsal heads were then removed at the surgical necks. The metatarsal parabola should be maintained after metatarsal head resection, so as not to create new areas of increased pressure that may also lead to ulcerations postoperatively. Closure of the dorsal wounds was performed in layers (deep to superficial) with suture material of the surgeon's choice. Postoperative treatment consisted of complete bed rest for 2 to 3 days, elevation of the operated extremity, appropriate antibiotic therapy, pain medications as needed, and initial nonweightbearing with crutches for the first 2 to 3 weeks. Sutures were removed at 2 to 3 weeks. Patients then progressed to complete weightbearing, with wooden-soled surgical shoes and advancing to full weightbearing in normal shoe gear. Results
Between August 1980 and April 1993, 27 patients underwent pan metatarsal head resections as previously described. There were 16 males and 11 females. The average patient age was 60.6 years, with a range of 43 to 80 years. Patients suffered from either diabetes or rheumatoid arthritis. Average duration of diabetes was 14.8 years, with a range of from 7 to 31 years (Table 1).
THE JOURNAL OF FOOT AND ANKLE SURGERY
TABLE 2
Clinical information/rheumatoid patients
Patient
2 3 4 5 6 7 8 9 10 11 12 13 14 15
Foot
Sex
Date
Left Right Left Right Right Left Right Left Right Right Left Right Right Right Left Left Left Right Left Right Right
F
3/82 7/82 3/82 5/83 6/83 12/85 10/86 9/88 6/89 3/89 3/89 2/92 6/89
F M F F F M M M M M M M M M
2190 4/90 4/90 4/91 8/92 3/93 5/91
2193
Months Prior to Ulcer Recurrence
location of Recurrence
Total Number of Months
62 0 0 0 97 69 42 0 38 0 0 0 18 0 0 0 0 0 0 0 0
sub 2nd MT
143 139 141 127 126 96 86 63 54 56 55 22 54 46 44 44 32 16 9 31 11
sub sub sub sub
2nd MT 2nd MT 2nd MT 3rd MT
sub 2nd MT
Number of Years Rheumatoid
6 8 20 19 19 8 19 10 3 10 5 8 14 13 2
Totals: Right = 12 Left = 9 Male = 10 Female = 5 F = female M = male MT = metatarsal
Average duration of rheumatoid arthritis was 10.9years, with a range of from 2 to 20 years (Table 2). Forty-one procedures were performed and evaluated retrospectively. Thirteen patients had pan metatarsal procedures performed bilaterally. One patient had contralateral pan metatarsal surgery 3 years after the initial pan metatarsal procedure. The results from 41 procedures were evaluated for recurrence rate of ulceration after pan metatarsal head resection. The average length of follow-up was 6 years and 2 months, with a range from 9 months to 13 years and 4 months. Primary healing was achieved in all 41 procedures. There were seven postoperative complications in the 27 patients. Three patients suffered early wound dehiscence of the lateral incision and were treated unevent-
fully. Two patients suffered from an early postoperative infection that was eradicated with appropriate antibiotic therapy. Another patient suffered from early hematoma formation, which resolved uneventfully. The most serious complication that occurred was a deep venous thrombosis. This was treated with appropriate heparin therapy and the patient was subsequently discharged from the hospital on coumadin. Eleven of the twenty-seven patients reulcerated. The average length of time for reulceration to occur was 4 years and 5 months, with the earliest reulceration at 6 months. The most delayed reulceration occurred 8 years and 8 months postoperatively. Eleven of the forty-one procedures reulcerated. This represented an average 27% recurTABLE 4
TABLE 3
Frequency of ulcer recurrence in diabetics
Frequency of ulcer recurrence in rheumatoid patients
Metatarsal Head
Percentage
Metatarsal Head
Percentage
First Second Third Fourth Fifth
16.50% 0% 33.50% 33.50% 16.50%
First Second Third Fourth Fifth
16.6% 50.00% 16.7% 0% 16.7%
VOLUME 35, NUMBER 6, 1996
575
FIGURE 2 Gross specimens of regeneration of metatarsal heads 2 through 5.
FIGURE 1 Roentgenographic illustration demonstrating osseous metatarsal regeneration after pan metatarsal surgery.
renee rate. The most frequent location of recurrence was the second metatarsal (41.6%) (Tables 3, 4). Discussion
There may be a number of reasons why a patient reulcerates after pan metatarsal head resection. For example, exacerbation of peripheral vascular disease; progression of a systemic condition such as diabetes mellitus or rheumatoid arthritis; poor control of diabetes postoperatively, or possible change in the normal weightbearing parabola of the foot secondary to the procedure itself, resulting in increased pressure areas on the plantar aspect of the foot, which may lead to reulceration. The authors, in their own experience, found that the most common etiological factor leading to reulceration was boney regeneration of the metatarsal heads (Fig. 1). This was initially determined by roentgenographic comparison of old versus recent films, and, secondly, through histopathological examination after revisional surgery. Radiographically, it appeared as if the metatarsal heads regenerated, either partially or fully. 576
FIGURE 3 Gross specimen of complete regeneration of a third metatarsal head.
Gross histopathological studies revealed boney regrowth of the metatarsal heads (Figs. 2-4). Microhisto pathological studies revealed new bone growth by the presence of many active osteoblasts in the marrow cavities (Fig. 5). The presence of the irregular nature of the cement lines versus the concentric nature of these lines, as is seen in old bone, is also indicative of new bone formation (Fig. 5). Dorland's Medical Dictionary" defines cement lines as a name applied to a line, visible in microscopic examination of bone in cross section, marking the boundary of an osteon (haversian system). Finally, the fact that very few osteocytes are seen, which are normally present in increased numbers in old bone, suggests this is regenerating bone formation (Fig. 6).
6 Dorland's Illustrated Medical Dictionary. 28th ed., p. 942, W. B. Saunders, Co., Philadelphia, PA, 1994.
THE JOURNAL OF FOOT AND ANKLE SURGERY
FIGURE 4 Gross specimen showing regeneration of a fifth metatarsal head.
FIGURE 8 A, Zone of fibrocartilage. B, Zone of fibrous connective tissue. C, Zone of regenerating bone with a few osteoclasts, increased fat cells, and osteoblastic activity signifying bone regeneration.
References
FIGURE 5 A, Active osteoblastic activity in regenerating bone. B, Fat cells. C, Irregular shape of the cement lines.
1. Hoffman, P. An operation for severe grades of contracted or clawed toes. Amer. J. Orthop. Surg. 9:441-448, 1911. 2. Clayton, M. L. Surgical treatment of the rheumatoid foot. In Foot Disorders, edited by Giannestras, N. J., pp. 319-340, Lea and Febiger, Philadelphia, 1967. 3. Kates, A, Kessel, L., Kay, A Arthroplasty of the forefoot. J. Bone Joint Surg. 49B:552-557, 1967. 4. Larmon, W. A Surgical treatment of deformities of rheumatoid arthritis of the forefoot and toes. Bull. Northwestern. Univ. Med. Sch. 25:39-42, 1951. 5. Hodor, L., Dobbs, B. Pan metatarsal head resection. J. Am. Podiatr. Assoc. 73:287-292, 1983. 6. Hugar, D. W., Gucfa, C. P. Pan metatarsal head resections: the Hoffman procedure. J. Am. Podiatr. Assoc. 64:983-986, 1977.
Conclusion
Although pan metatarsal head resection has been an accepted and effective procedure for the management of both the painful, arthritic foot and the neuropathic foot, it is not without complications. The main problem is metatarsal head regeneration, ultimately resulting in reulceration. The podiatric surgeon should be aware of this complication as a potential postoperative occurrence.
Additional References Giurini, J. M., Basile, P., Chrzan, J. S. Pan metatarsal head resection: a viable alternative to the transmetatarsal amputation. J. Am. Podiatr. Med. Assoc. 83:101-107, 1993. Giurini, J. M., Habershaw, G. Pan metatarsal head resection in chronic neuropathic ulceration. J. Foot Surg. 26:249-252, 1987. Tillo, T. H., Giurini, J. M., Habershaw, G. M. Review of metatarsal osteotomies for the treatment of neuropathic ulcerations. J. Am. Podiatr. Med. Assoc. 80:211-217, 1990.
VOLUME 35, NUMBER 6, 1996
577