Direction and location of the nutrient artery to the fifth metatarsal at risk in osteotomy for bunionette
Introduction
Bunionette, also known as “tailor’s bunion”, is characterized by lateral prominence of the fifth metatarsal head with associated varus of the metatarsophalangeal joint [1]. The symptoms are mechanically induced and often associated with hyperkeratotic lesions and adventitious bursae [2]. If nonoperative treatments fail, surgical treatments are considered, including lateral condylectomy of the fifth metatarsal head [3], fifth metatarsal distal metaphyseal osteotomy [4], [5], [6], fifth metatarsal diaphyseal osteotomy [7], [8], [9], [10], [11], and fifth metatarsal proximal osteotomy [12], [13], [14], [15], [16]. Proximal osteotomies provide good correction for severe deformity, but the possibility of complications such as damage to the vascular supply to the fifth metatarsal has been reported [14], [15].
These complications, which include nonunion and delayed union of the fifth metatarsal, may be related to disruption of the nutrient artery supplying the fifth metatarsal and have prompted recommendations to restrict use of proximal metatarsal osteotomy. There was the report that described delayed union in 3 of 10 patients who underwent proximal dome osteotomy to the proximal third of the diaphysis [16]. Non-union and delayed union might be rare but cause serious problems when they occur.
The location of the artery feeding the first metatarsal has been described in a few reports [17], [18], [19], [20]. However, there has been no study describing in detail the direction of the nutrient artery supplying the fifth metatarsal. The aims of this study were to assess the direction and location of the nutrient artery supplying the fifth metatarsal in fresh cadavers on coronal and axial enhanced computed tomography (CT) and to identify factors that could help to prevent injury to this artery during osteotomy for bunionette.
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Materials and methods
This study was approved by the research board at our institution and included 10 feet of 10 fresh cadavers (7 male, 3 female; mean age 76 years at the time of death). Cadavers with a history or signs of previous ankle trauma or surgery, congenital or developmental deformity, or inflammatory arthritis were excluded after checking their clinical records and CT images. The left fifth metatarsal of one specimen was dissected for anatomical observation.
The vessels were flushed with warm normal
Results
The nutrient artery was found to arise from the fourth plantar metatarsal artery in all feet, similar to the description in previous report [20]. A summary of the results is shown in Table 2.
The mean distance from the distal epiphysis to the point of entry of the nutrient artery to the fifth metatarsal in the coronal plane was 42 ± 4 (range 35–49) mm. The mean distance from the lateral or medial proximal epiphysis to the entry point of the nutrient artery in the coronal plane was 23 ± 4 (range
Discussion
In this study, the nutrient artery was observed to enter the fifth metatarsal around the junction of the middle and proximal thirds of the diaphysis in all cases ion the coronal plane, similar to findings reported previously [17], [18], [19], [20]. In our study, the mean distance from the medial-proximal epiphysis to the point of entry of the nutrient artery to the fifth metatarsal was 15 (range 8–22) mm, whereas there was the report that the foramen of the nutrient artery was on average 26
Conclusions
In conclusion, this is the report showing that the point of entry of the nutrient artery supplying the fifth metatarsal enters around the junction of the middle and proximal thirds of the medial aspect of the fifth metatarsal. The nutrient artery enters the fifth metatarsal in a distal direction in the coronal plane and in a medial-plantar direction in the axial plane. The direction and location of the nutrient artery supplying the fifth metatarsal is important when performing an osteotomy for
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Conflicts of interest
None.
Acknowledgements
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
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