What is the treatment for soft tissue calcifications near the metatarsal head?

Treatment for Soft Tissue Calcifications Near the Metatarsal Head

For soft tissue calcifications near the metatarsal head, metatarsal head (MTH) resection in combination with an appropriate offloading device is recommended when non-surgical interventions have failed, particularly if there is evidence of infection or osteomyelitis. 1

Assessment and Initial Management

• Evaluate the calcification's characteristics:

  • Location relative to metatarsal head
  • Presence of associated ulceration
  • Evidence of infection or osteomyelitis
  • Impact on foot biomechanics and gait

• First-line conservative treatment options:

  • Offloading devices (non-removable preferred)
  • Debridement of hyperkeratotic tissue
  • Felted foam padding in combination with appropriate footwear 1
  • Cushioning to redistribute pressure

Treatment Algorithm

Step 1: Non-surgical Offloading Interventions

1. Primary choice: Non-removable knee-high offloading device (total contact cast or non-removable walker) 1
2. Secondary choice: Removable knee-high or ankle-high offloading device if non-removable device is contraindicated 1
3. Tertiary choice: Felted foam with appropriate footwear if devices unavailable 1

Step 2: Surgical Management (if non-surgical treatment fails)

Based on the 2023 IWGDF guidelines, surgical options include:

1. For metatarsal head calcifications with ulceration:

   • Metatarsal head resection in combination with an offloading device 1
   • Shows moderate increases in ulcer healing (RR 1.33) and sustained healing (RR 1.21)
   • Decreases risk of infection (RR 0.55) and amputation (RR 0.68)

2. For hallux-related calcifications:

   • Joint arthroplasty in combination with an offloading device 1, 2
   • Particularly effective for hallux ulcers with limited range of motion

3. For calcifications with flexible toe deformities (digits 2-5):

   • Digital flexor tenotomy to promote and sustain healing 1
   • Highly effective with 92-100% healing rates in 21-40 days 1

4. For calcifications with equinus deformity:

   • Achilles tendon lengthening in combination with offloading device 1

Special Considerations

Presence of Infection

• For mild infection: Consider using a non-removable knee-high offloading device 1
• For moderate infection: Use a removable offloading device 1
• For severe infection: Address infection first, then use removable offloading based on individual factors 1

Post-Surgical Care

• Continue appropriate offloading after surgical intervention
• Monitor for transfer lesions, which can occur at a higher rate (RR 1.50) after MTH resection 1
• Provide appropriate footwear modifications (wide toe box, rocker-bottom soles) 2

Cautions and Pitfalls

1. Risk of transfer lesions: MTH resection may lead to new lesions in other areas (RR 1.50) 1
2. Reduced activity: Surgical interventions may decrease weight-bearing activity 1
3. Temporary quality of life impact: Quality of life may decrease during healing but improve after healing 1
4. Vascular assessment: Always evaluate vascular status before surgical intervention 2

The evidence strongly supports surgical intervention for persistent soft tissue calcifications near the metatarsal head when conservative measures fail, with metatarsal head resection showing the most favorable outcomes for healing and preventing complications.