Lesser metatarsal surgery: A guide for patients

Lesser metatarsal problems can present as pain at the ball of the foot, which is often described as like walking on a marble. Often there may be some hard skin under the joint and a deformity of the associated toe.

The most common problem associated with lesser metatarsals is hard skin or corn formation as well as injury to the joint capsule itself. This is called capsulitis. Often the ligamentous around the joint become injured and when this occurs the toe can become hammered or clawed. Osteoarthritis can also occur, in this condition the cartilage in the joint is damaged and produces pain.

What causes lesser metatarsal problems?

Lesser metatarsal problems can be due to their position or length, be secondary to a bunion deformity or due to an inflammatory or degenerative condition, such as rheumatoid or osteoarthritis.

When the metatarsal is the cause of the problem, often it is either too long or prominent on the sole of the foot and is subjected to increased pressure from the ground.

In the case of a bunion deformity, as the size of the bunion increases the big toe joint takes less weight than it should do. This weight is then transferred to the smaller joints, which are not designed to withstand so much pressure and, over time, the joint can become injured.

Other problems can also lead to lesser metatarsal pain such as:

• osteoarthritis (non-inflammatory arthritis)
• rheumatoid/psoriatic arthritis (inflammatory arthritis)
• crystal arthropathy, for example, gout
• fracture
• corns
• avascular necrosis or Freiberg’s disease: Interruption of the blood supply to the metatarsal head, often associated with trauma.

What treatment options are available?

Conservative and surgical treatment can help solve lesser tatarsal problems.

Conservative management

• Walking trainers
• Steroid injections
• Insoles
• Calf stretching exercises.

A course of conservative treatment is carried out before any surgical management as this can often solve the problem. If conservative care does not work surgical management may be required.

Surgical management

Long metatarsals

If the metatarsal is long and producing problems, shortening it can reduce the pressure onto the joint. The operation involves cutting the head of the metatarsal into two separate portions and then sliding the bottom portion back to shorten it. Once the correct length has been achieved, a screw is used to secure the bone and allow it to heal.

Specific complications of this procedure include:

• feeling of stiffness (2.40per cent)
• toe does not touch ground - floating toe (this can often be solved by stretching exercises)
• transfer of pressure to adjacent metatarsal head (2.88%)
• non-union of bone (bone does not knit together) (0.48%)
• fixation problems (with the screws/pins) (2.4%)
• shortening of the toe
• continued pain at surgery site (7.69%).

 Often, this procedure is performed in combination with others to correct any associated toe deformity. If this is the case, you will be given a leaflet about toe surgery.

Prominent metatarsals

If the metatarsal is prominent on the sole of the foot but the length of the metatarsal is normal, the metatarsal is usually elevated. Following this, a screw will be placed in the bone to allow the fragments to heal.

Specific complications of this procedure include:

• feeling of stiffness (2.40%)
• toe does not touch ground - floating toe (this can often be solved by stretching exercises)
• transfer of pressure to ball of foot (2.88%)
• non-union of bone (bone does not knit together) (0.48%)
• fixation problems (with the screws/pins) (2.4%)
• shortening of the toe.

Degenerated joints

There are a number of different procedures to manage degenerative arthritis of the lesser metatarsals. These can include remodelling or removing the joint, as well as silicone joint replacements. Remodelling the joint involves removing bony outgrowths, but this does not improve damaged cartilage.

Silastic joint implants are non-reactive pieces of silicone. In a very small number of people a reaction to the silicone can take place. If this happens the implant is removed. The implant acts as a spacer and allows some movement at the joint. The silastic joint has a lifespan of roughly 10 to 15 years. After this time, it may need replacing.

Specific complications of this procedure include:

• failure of the implant
• reaction to the implant
• elevation of the second toe
• transfer.

If the joint is very badly damaged or out of alignment, then the head of the metatarsal and sometimes the base of the toe bone are removed to produce a false joint.

Specific complications of this procedure include:

• shortening of the toe
• transfer pain/lesion to adjacent joints in the ball of the foot
• reduced function/stability of the toe.

About day case surgery under local anaesthetic

Surgery is carried out under local anaesthetic as a day case. This means that you are awake during the operation, but a screen will prevent you from seeing the operation.

To numb your foot, you will be given some injections around your ankle or behind the back of the knee. You can eat and drink on the day of surgery, there is no need for fasting.

The operation may take up to 40 minutes but you should be prepared to be at the hospital longer than this to allow for preparation and recovery.

If you decide on surgery, you will be invited back for a pre-surgical clinic. A member of the nursing team will take your medical history. If you are on any medication, please bring a list with you. This is a good opportunity to ask us any questions and discuss any concerns you may have.

You must have a competent adult at home for the first day and night after surgery.

There are many different types of operations for lesser metatarsal problems and the recovery for each varies. It is important to remember that if screws and wires are used to fix and allow healing of a bone, you will not be able to drive and must restrict your activity, such as no long walks or  high-impact activities such as shopping. If you do not do this, there is a risk you could dislodge the screw/wire and cause the bony surfaces to separate or fracture. If this happens, it would have a serious impact on your recovery.

Recovery after your operation

The first two to three days

• You must rest with your foot elevated to hip.
• You should restrict your walking to bathroom visits only. If you have been given crutches, you must use them in the way shown. You may be able to bear a little weight on the foot.
• You should take the prescribed pain killers. If you experience pain, it is usually worse for the first two days.
• If you are still experiencing pain after three to four days that is not relieved by the painkillers, you should contact the department.
• If you have any concerns regarding your foot, you should contact the department directly.
• The department is closed at the weekend. Out-of-hours you should contact your GP or go to your local accident and emergency (A&E) department.

Two weeks after surgery

• Two weeks after the operation you must visit for your stitches to be removed.
• You should no longer need a bandage and be able to wear a normal shoe again. As your foot will tend to swell, you need to wear a roomy running lace-up trainer. If you do not have any, you will need to buy some before surgery. You do not need to spend a lot of money on these.
• Two days after the stitches have been removed you can start bathing the foot normally.
• At this stage, you can gradually and gently increase your activities. You will still need to rest between activities.
• You will also be given a rigorous regime of exercises to regain strength and flexibility in the toe joint.
• After the stitches have been removed and, if you have not had any wires or screws placed in the bone, you can consider driving. However, you must feel able to perform an emergency stop. Please check with your insurance company about when your policy covers you to drive.

Between two and six weeks after surgery

• During this time the foot gradually returns to normal and you may be able to vary your footwear.
• At three weeks, and if no wires or screws have been placed in the foot and your job does not involve you being on your feet for long periods of time or excessive stresses to the foot, you can consider a return to work.
• Sixty per cent of patients have returned to roomy shoes at six weeks, and 90 per cent in eight weeks.
• There will still be noticeable swelling, especially towards the end of the day. This is quite normal.
• If screws or wires have been placed in the foot, you can look at returning to work after six weeks; depending on the type of work and footwear required. For certain jobs, this could be unrealistic.
• Again, if screws and wires have been placed in the foot, at six weeks you can generally return to driving, however you must feel able to perform an emergency stop. Please check with your insurance company about when your policy covers you to drive.
• Although normal everyday activities will be possible, sporting activities are still restricted.
• At six weeks, if no screws or wires have been placed in the foot, you can think about returning to sporting activities. If your foot swells and becomes painful you need to abstain for longer.

Between six and twelve weeks after surgery

• The foot should now be comfortable and returning to normal but there may still be some swelling.
• If screws and wires have been placed in the foot, you can consider returning to sporting activities/gym work at 12 weeks. If your foot swells and becomes painful you need to abstain for longer.

Six months after surgery

The residual swelling should now be very slight, although the healing process continues for a year. You should be getting full benefit from the surgery.

Twelve months after the surgery

All healing is now complete.

Frequent or serious occurring risks

All operations carry a small risk of complications. In foot surgery, complications are uncommon and most are resolved without permanent disability or pain.

General and specific complications of this procedure include:

• infection (two in 100)
• delayed healing of the skin (eight in 100)
• non-compliance of patients (four in 100)
• bone break associated with non-compliance (two in 100)
• prolonged swelling post operatively (four in 100)
• thick or sensitive scar formation (four in 100)
• loosening or movement of the screw or wire used to fix the bones (two in 100)
• shortening of the toe
• the toe may become stiff (one in 100)
• toe does not touch ground - floating toe (this can often be solved by stretching exercises)
• transfer pain/lesion to adjacent joints in the ball of the foot
• recurrence of arthritic symptoms
• blood clot deep vein thrombosis (DVT).

Complications following foot surgery are rare events but can happen. It is important to remember that if there is a complication, you will need to visit the hospital more frequently and there could be a significant impact on your recovery and return to work time. Foot surgery should be avoided if only for cosmetic gains.