The Journal of Foot & Ankle Surgery 60 (2021) 595−599

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The Journal of Foot & Ankle Surgery

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Case Reports and Series

Avascular Necrosis of the First Metatarsal: A Case of Second Metatarsal Bone

Transport with External Fixation
Bradley M. Lamm, DPM, FACFAS1, Kyle R. Moore, DPM, FACFAS2,
Matthew Hentges, DPM, FACFAS3, Lanster R. Martin, DPM4, Jordan J. Ernst, DPM, MS5
1
Chief of Foot & Ankle Surgery, Director, Foot & Ankle Deformity Center, Director, Foot & Ankle Deformity Correction Fellowship, The Paley Institute at St. Mary’s
Medical Center and Palm Beach Children’s Hospital, West Palm Beach, FL
2
Fellowship Trained Foot & Ankle Surgeon, Ankle and Foot Center of Tampa Bay, South Tampa, FL
3
Fellowship Trained Foot & Ankle Surgeon, Faculty, Foot and Ankle Surgery Residency Program, Allegheny Health Network, West Penn Hospital, Pittsburgh, PA
4
Fellowship Trained Foot & Ankle Surgeon, Baylor Scott and White Health System, College Station, TX
5
Deformity Correction Fellow, The Paley Institute at St. Mary’s Medical Center and Palm Beach Children’s Hospital, West Palm Beach, FL

A R T I C L E I N F O A B S T R A C T

Level of Clinical Evidence: 4 Avascular necrosis (AVN) after bunion surgery is an unfortunate complication which can be devastating and pain-
Keywords: ful. We present a case report of gradual medializing transport of the second metatarsal with external fixation to
bone graft repair a large bone defect caused by AVN affecting >50% of the first metatarsal. The procedure was performed on a
bunion 49-year-old female who suffered AVN after failed bunion surgery. At 12-month follow up, first ray position and
external fixation length were maintained. With respect to the second ray, there were no clinically significant issues. The second
HAV digit was mildly elevated but there was no frank instability of the toe or of the Lisfranc complex. The patient was
Ilizarov pain free and had returned to her desired daily activities.
reconstruction © 2019 by the American College of Foot and Ankle Surgeons. All rights reserved.
revision surgery

Avascular necrosis (AVN) of the first metatarsal is a known complica- knowledge, this is the first reported use of this technique for a first
tion of the chevron osteotomy for bunion correction. The incidence of AVN metatarsal defect.
after distal first metatarsal osteotomy is a source of debate, ranging in the
literature from 0% to 40% (1,2). Inarguable, however, is the devastating Case Study
affect that AVN can have on obtaining a successful reconstructive result.
Large, segmental bone defects of the foot present unique reconstruc- A 49-year-old female with history of first metatarsal nonunion and
tive challenges. Goals of reconstruction include restoration of length, avascular necrosis after a distal first metatarsal osteotomy was referred
preservation of adjacent joint function when possible, and return to to the practice of the senior author (BML) for surgical reconstruction.
activity on a pain-free and biomechanically balanced foot. The etiology The index procedure was performed 2 years prior. When AVN was
of segmental bone defects can include trauma, bone void after tumor diagnosed after her initial surgery, she underwent a revision attempt
resection, osteomyelitis, nonunion, and avascular necrosis. Ilizarov consisting of acute lengthening and bone grafting of the first metatarsal
bone transport has been widely practiced across the world and is a pre- with internal fixation. This resulted in nonunion and refracture of the
ferred method by many reconstructive surgeons to manage large long first metatarsal, and all internal fixation was removed. The patient had
bone defects (3). persistent pain and swelling to the medial foot and was unable to
In this report, the authors present a unique method of treating ambulate without the use of a gait aid and fracture boot. Her medical
severe first metatarsal AVN after failed bunion surgery, through gradual history was otherwise unremarkable.
medial transport of the second metatarsal with external fixation. To our On initial presentation to the senior author, she had a closed soft-tis-
sue envelope without infection and was neurovascularly intact. The hal-
lux was in a shortened and elevated position (Figs. 1 and 2). First
Financial Disclosure: None reported. metatarsophalangeal joint range of motion was limited to 35° of dorsi-
Conflict of Interest: None reported. flexion and 10° of plantarflexion and was painful throughout the range
Address correspondence to: Bradley M. Lamm, DPM, FACFAS, Chief of Foot & Ankle
Surgery, The Paley Institute at St. Mary’s Medical Center and Palm Beach Children’s Hospi-
of motion. There was pain to palpation of the entire first ray and plantar
tal, 901 4th Street, Kimmel Building, West Palm Beach, FL 33407. second metatarsal head. Radiographically, there was extensive shorten-
E-mail address: [email protected] (B.M. Lamm). ing, resorption, fragmentation, and sclerosis noted to the first

1067-2516/$ - see front matter © 2019 by the American College of Foot and Ankle Surgeons. All rights reserved.
https://doi.org/10.1053/j.jfas.2019.04.008
596 B.M. Lamm et al. / The Journal of Foot & Ankle Surgery 60 (2021) 595−599

Fig. 3. Anterior posterior radiograph at initial presentation revealing extensive shorten-

ing, resorption, fragmentation, and sclerosis to the first metatarsal.
Fig. 1. Note the shortened position of the hallux on initial presentation.

to allow for fusion at proximal and distal aspect of second metatarsal

metatarsal (Fig. 3). Magnetic resonance imaging showed AVN (which was now in the position of the resected first metatarsal). The
compromising the majority of the first metatarsal (Fig. 4). After compre- patient was allowed to weight-bear as tolerated in a wooden-bottom
hensive deformity planning, the patient was scheduled for a 2-staged surgical shoe throughout her treatment course. Radiographic union of
reconstruction. the docking sites were noted 8 weeks postoperatively as evidenced by
The first stage consisted of thorough debridement of nonviable first uniform trabeculation across the gaps between the transported bone
metatarsal bone and spanning of the medial column with a monolateral and native bone; no radiographic signs of infection, osteolysis, or avas-
external fixation device (Figs. 5 and 6). First metatarsal tissue and bone cular necrosis to the transported metatarsal were present. All incisions
specimens were negative for histologic evidence of osteomyelitis or and surgical wounds healed without complication.
bacterial growth. The second metatarsal was captured by 2 parallel At 12-month follow up, the first ray position and medial column
transverse external monolateral fixators that were fixated medially to length were maintained (Figs. 8 and 9). The patient had no complaints
the second metatarsal and laterally to the fourth and fifth metatarsals. of pain and was able to return to her desired daily activities. There was
An osteotomy of the proximal metaphyseal second metatarsal was per- excellent alignment of the hallux, and, clinically, the second digit was
formed with careful attention to preserve the base and insertion of the only minimally shortened and elevated. There was hypertrophy and
Lisfranc ligament. An adjustment schedule was made to include 17 mm remodeling of the transported second metatarsal, indicating its viability
of longitudinal distraction of the medial column, 14 mm of medial and intact vascularity (Fig. 10).
transport of the proximal second metatarsal, and 24 mm medial trans-
port of the distal second metatarsal. Medial column distraction and sec-
ond metatarsal transport was performed at a rate of 0.5 mm per day, for Discussion
a total correction time of 34 days.
The second stage of the reconstruction (Fig. 7) consisted of removing Small bony defects can be managed with debridement of the dis-
the 2 transverse fixators and modification to the medial external fixator eased bone and autogenous or allogenic grafting. However, treatment
of large segmental defects requires advanced reconstructive strategies
(4). There have been many surgical techniques proposed to manage
long bone defects. Examples of such strategies include the Masquelet or
induced membranes technique, vascularized autograft transfer, and
bone transport with external fixation. Alain Masquelet described a tech-
nique involving excision of the diseased tissue and placement of a tem-
porary cement spacer in the bone void. A pseudomembrane rich in
mesenchymal stem cells forms around the cement spacer, which is later
carefully removed and the resultant membranous void filled with bone
graft (5). Vascularized fibular grafts have been used to treat large bone
defects of the tibia. Vascularized autograft transfer continues to be fur-
ther refined with the advancement of microsurgical techniques and
recently published results are favorable (4).
Many authors have reported success with using fibular transport for
large tibial defects (6−12). In 2000, Paley and Maar (3) reported on Ili-
Fig. 2. Note the shortened and elevated position of the hallux on initial presentation. zarov bone transport in 19 patients with tibial defects averaging 10 cm,
 B.M. Lamm et al. / The Journal of Foot & Ankle Surgery 60 (2021) 595−599 597

Fig. 4. Extensive avascular necrosis of the first metatarsal. (A) T1-weighted axial cut. (B) T2-weighted axial cut. (C) T1-weighted sagittal cut. (D) T2-weghted sagittal cut.

with union achieved in all cases. The results were graded as excellent in union, nonunion, AVN of the transported metatarsal, or infection were
15 patients, good in 3, and poor in 1. encountered. When compared with allograft, the transported bone carries
We have presented a unique application of bone transport for the no risk of immunogenicity and theoretically will not be subject to pro-
management of a large first metatarsal bone defect caused by avascular longed incorporation times frequently noted in large volume bone grafts.
necrosis, with an excellent result. The second metatarsal was successfully The potential biomechanical ramifications of disrupting the second
transported to the medial column and fused with the great toe to restore ray in this case were carefully considered before performing this proce-
function and length to the first ray. No complications such as delayed dure. The weightbearing configuration of the foot is likened to a

Fig. 5. Stage 1 of the reconstruction. A medial monolateral fixator is spanning the Fig. 6. Anteroposterior radiograph of stage 1 reconstruction. The medial monolateral fix-
debrided first metatarsal. Two transverse monolateral fixators are in place to transport ator is spanning the debrided first metatarsal. Two transverse monolateral fixators in
the second metatarsal medially. place to transport second metatarsal medially.
598 B.M. Lamm et al. / The Journal of Foot & Ankle Surgery 60 (2021) 595−599

Fig. 7. Second stage of the procedure, which consisted of removing the two transverse
fixators and modifying the medial external fixator to allow for fusion at the proximal and
distal aspects of the second metatarsal (second metatarsal was now in the position of the
resected first metatarsal).

Fig. 9. Clinical photos at (A) initial presentation and at (B) 12-month follow up after sec-
balanced “tripod” with force distribution to the first metatarsal head,
ond metatarsal transport procedure. Note the improved length and position of the hallux
fifth metatarsal head, and heel. The goals of correction included restora- with minimal elevation and shortening of second toe.
tion of this “tripod,” and we believed the potential downfalls of disrupt-
ing the second ray were outweighed by the importance of
reestablishing first ray function. The base of the second metatarsal was significant problems related to the shortened and elevated second digit
preserved to avoid destabilizing the Lisfranc joint and transverse arch. position. The patient did not complain of pain or complications involv-
The patient had no symptoms or radiographic evidence that would sug- ing the second toe.
gest disruption of the Lisfranc joint throughout the course of transport In conclusion, we present a successful case of gradual second meta-
or at final follow up. Interestingly, although the second digit had no tarsal transport to treat a large bone defect of the first metatarsal from
support from its respective metatarsal, the patient had no clinically AVN after failed bunion surgery. Bone transport is a reliable method for
treating large bone defects in the lower extremity. Successful execution
requires a thorough knowledge of surgical anatomy and external fixa-
tion principles.

Fig. 8. Comparison of clinical photos at initial presentation (A) and at 12-month follow up
(B) after second metatarsal transport procedure. Note the improved length and position
of the hallux with minimal elevation and shortening of the second toe. Fig. 10. Anteroposterior radiograph taken 12 months after the 2-staged procedure.
 B.M. Lamm et al. / The Journal of Foot & Ankle Surgery 60 (2021) 595−599 599

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