Functional and aesthetic evaluation of external fixator lengthening through plantar approach for fourth brachymetatarsia_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

ZHANG Jiadong , ZHANG Ning , HUANG Zheng , WANG Yang ,  XU Wenpeng ,  HU Yong

Department of Hand Surgery/Foot and Ankle Surgery, the Second Qilu Hospital of Shandong University, Foot and Ankle Research Center of Shandong University, Jinan Shandong, 250033, P. R. China;

Corresponding author：

XU Wenpeng, Email: chinaowenxu@126.com; HU Yong, Email: handsurgeon@163.com

Keywords：

Brachymetatarsia; congenital deformity; plantar approach; external fixation

DOI：

10.7507/1002-1892.202505022

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Objective To evaluate the functional and aesthetic evaluation of external fixator lengthening through plantar approach for fourth brachymetatarsia. Methods A retrospective analysis was conducted on 20 patients (23 feet) with fourth brachymetatarsia who met the selection criteria between January 2016 and January 2024, including 3 males and 17 females, with 8 left, 9 right, and 3 bilateral cases. The mean age was 24.7 years (range, 14-51 years). The preoperative metatarsal shortening length was (13.8±3.2) mm. The preoperative American Orthopaedic Foot and Ankle Society (AOFAS) forefoot score was 79.5±3.9, the visual analogue scale (VAS) score of appearance satisfaction was 1.7±0.8, and the appearance index (AI) score was 13.6±0.9. All patients underwent external fixator lengthening through plantar approach. The lengthening length of metatarsal bone, lengthening ratio, healing time, and healing index were recorded. Functional outcomes were assessed using the AOFAS forefoot score, VAS score of appearance satisfaction, and quality-of-life impact with AI questionnaire. Results All 20 patients were followed up for an average of 36.3 months (range, 14-55 months). During the follow-up, complications occurred in 4 cases (17.4%), including 2 cases of metatarsophalangeal joint stiffness, which had no significant effect on the function and appearance. Delayed union of osteotomy occurred in 1 case (healed at 12 weeks after operation). Pin loosening occurred in 1 case and recovered after outpatient reinforcement. No complications related to plantar scar occurred. At last follow-up, the lengthening length of metatarsal bone was (13.9±3.1) mm, and the lengthening ratio was 25.8%±5.6%. All cases achieved bony union, with a mean healing time of (64.3±12.5) days and a healing index of (46.9±4.8) d/cm. At last follow-up, AOFAS score was 98.9±2.1, the VAS score of appearance satisfaction was 9.3±0.7, and the AI score was 0.6±0.8, which significantly improved when compared with those before operation (t=27.398, P<0.001; t=32.994, P<0.001; t=56.135, P<0.001). Conclusion External fixator lengthening through plantar approach is a safe and effective technique for fourth brachymetatarsia, achieving satisfactory functional and aesthetic outcomes.

1.	Hosny GA, Ahmed AS. Distraction osteogenesis of fourth brachymetatarsia. Foot Ankle Surg, 2016, 22(1): 12-16.
2.	Zhu D, Lefèvre M, Fernandez A, et al. Brachymetatarsia: Surgical management, case report, and literature review. Case Rep Orthop, 2022. doi: 10.1155/2022/8253096.
3.	Li X, Gu J, Wu Y, et al. Treatment of fourth metatarsal brachymetatarsia using distraction osteogenesis with external fixator: Surgical techniques, outcomes and complications. Orthop Surg, 2024, 16(9): 2148-2156.
4.	Woo SH, Bang CY, Ahn HC, et al. Anatomical reconstruction of the fourth brachymetatarsia with one-stage iliac bone and cartilage cap grafting. J Plast Reconstr Aesthet Surg, 2017, 70(5): 666-672.
5.	Fuiano M, Mosca M, Caravelli S, et al. Callus distraction with external fixator for the treatment of congenital brachymetatarsia of the fourth ray. Foot Ankle Surg, 2020, 26(6): 693-698.
6.	Jones MD, Pinegar DM, Rincker SA. Callus distraction versus single-stage lengthening with bone graft for treatment of brachymetatarsia: A systematic review. J Foot Ankle Surg, 2015, 54(5): 927-931.
7.	Davidson RS. Metatarsal lengthening. Foot Ankle Clin, 2001, 6(3): 499-518.
8.	Lamm BM. Percutaneous distraction osteogenesis for treatment of brachymetatarsia. J Foot Ankle Surg, 2010, 49(2): 197-204.
9.	Zhang N, Xu H, Huang Z, et al. Plantar approach for treatment of brachymetatarsia: A novel approach with an aesthetic consideration. J Plast Reconstr Aesthet Surg, 2022, 75(5): 1668-1673.
10.	Waizy H, Polzer H, Schikora N, et al. One-stage metatarsal interposition lengthening with an autologous fibula graft for treatment of brachymetatarsia. Foot Ankle Spec, 2019, 12(4): 330-335.
11.	Giannini S, Faldini C, Pagkrati S, et al. One-stage metatarsal lengthening by allograft interposition: a novel approach for congenital brachymetatarsia. Clin Orthop Relat Res, 2010, 468(7): 1933-1942.
12.	Peña-Martínez VM, Palacios-Barajas D, Blanco-Rivera JC, et al. Results of external fixation and metatarsophalangeal joint fixation with K-wire in brachymetatarsia. Foot Ankle Int, 2018, 39(8): 942-948.
13.	McGlamry ED, Cooper CT. Brachymetatarsia: a surgical treatment. J Am Podiatry Assoc, 1969, 59(7): 259-264.
14.	Choudhury SN, Kitaoka HB, Peterson HA. Metatarsal lengthening: case report and review of literature. Foot Ankle Int, 1997, 18(11): 739-745.
15.	Ortiz-Romero M, Fernández-Garzón Á, Caceres-Matos R, et al. One-stage technique with calcaneal graft for the treatment of brachymetatarsia: A case report. Medicina (Kaunas), 2025, 61(3): 497. doi: 10.3390/medicina61030497.
16.	Kim JS, Baek GH, Chung MS, et al. Multiple congenital brachymetatarsia. A one-stage combined shortening and lengthening procedure without iliac bone graft. J Bone Joint Surg (Br), 2004, 86(7): 1013-1015.
17.	Hamada M, Sakamoto Y, Nagasao T, et al. Treatment of complications after distraction osteogenesis for brachymetatarsia of the fourth metatarsal. Plast Reconstr Surg Glob Open, 2016, 4(7): e817. doi: 10.1097/GOX.0000000000000836.
18.	Lee KB, Park HW, Chung JY, et al. Comparison of the outcomes of distraction osteogenesis for first and fourth brachymetatarsia. J Bone Joint Surg (Am), 2010, 92(16): 2709-2718.

1. Hosny GA, Ahmed AS. Distraction osteogenesis of fourth brachymetatarsia. Foot Ankle Surg, 2016, 22(1): 12-16.
2. Zhu D, Lefèvre M, Fernandez A, et al. Brachymetatarsia: Surgical management, case report, and literature review. Case Rep Orthop, 2022. doi: 10.1155/2022/8253096.
3. Li X, Gu J, Wu Y, et al. Treatment of fourth metatarsal brachymetatarsia using distraction osteogenesis with external fixator: Surgical techniques, outcomes and complications. Orthop Surg, 2024, 16(9): 2148-2156.
4. Woo SH, Bang CY, Ahn HC, et al. Anatomical reconstruction of the fourth brachymetatarsia with one-stage iliac bone and cartilage cap grafting. J Plast Reconstr Aesthet Surg, 2017, 70(5): 666-672.
5. Fuiano M, Mosca M, Caravelli S, et al. Callus distraction with external fixator for the treatment of congenital brachymetatarsia of the fourth ray. Foot Ankle Surg, 2020, 26(6): 693-698.
6. Jones MD, Pinegar DM, Rincker SA. Callus distraction versus single-stage lengthening with bone graft for treatment of brachymetatarsia: A systematic review. J Foot Ankle Surg, 2015, 54(5): 927-931.
7. Davidson RS. Metatarsal lengthening. Foot Ankle Clin, 2001, 6(3): 499-518.
8. Lamm BM. Percutaneous distraction osteogenesis for treatment of brachymetatarsia. J Foot Ankle Surg, 2010, 49(2): 197-204.
9. Zhang N, Xu H, Huang Z, et al. Plantar approach for treatment of brachymetatarsia: A novel approach with an aesthetic consideration. J Plast Reconstr Aesthet Surg, 2022, 75(5): 1668-1673.
10. Waizy H, Polzer H, Schikora N, et al. One-stage metatarsal interposition lengthening with an autologous fibula graft for treatment of brachymetatarsia. Foot Ankle Spec, 2019, 12(4): 330-335.
11. Giannini S, Faldini C, Pagkrati S, et al. One-stage metatarsal lengthening by allograft interposition: a novel approach for congenital brachymetatarsia. Clin Orthop Relat Res, 2010, 468(7): 1933-1942.
12. Peña-Martínez VM, Palacios-Barajas D, Blanco-Rivera JC, et al. Results of external fixation and metatarsophalangeal joint fixation with K-wire in brachymetatarsia. Foot Ankle Int, 2018, 39(8): 942-948.
13. McGlamry ED, Cooper CT. Brachymetatarsia: a surgical treatment. J Am Podiatry Assoc, 1969, 59(7): 259-264.
14. Choudhury SN, Kitaoka HB, Peterson HA. Metatarsal lengthening: case report and review of literature. Foot Ankle Int, 1997, 18(11): 739-745.
15. Ortiz-Romero M, Fernández-Garzón Á, Caceres-Matos R, et al. One-stage technique with calcaneal graft for the treatment of brachymetatarsia: A case report. Medicina (Kaunas), 2025, 61(3): 497. doi: 10.3390/medicina61030497.
16. Kim JS, Baek GH, Chung MS, et al. Multiple congenital brachymetatarsia. A one-stage combined shortening and lengthening procedure without iliac bone graft. J Bone Joint Surg (Br), 2004, 86(7): 1013-1015.
17. Hamada M, Sakamoto Y, Nagasao T, et al. Treatment of complications after distraction osteogenesis for brachymetatarsia of the fourth metatarsal. Plast Reconstr Surg Glob Open, 2016, 4(7): e817. doi: 10.1097/GOX.0000000000000836.
18. Lee KB, Park HW, Chung JY, et al. Comparison of the outcomes of distraction osteogenesis for first and fourth brachymetatarsia. J Bone Joint Surg (Am), 2010, 92(16): 2709-2718.

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