What is the treatment approach for soft tissue calcification of the metatarsal head?

Treatment Approach for Soft Tissue Calcification of the Metatarsal Head

Metatarsal head resection in combination with an appropriate offloading device is the recommended treatment for soft tissue calcification of the metatarsal head when non-surgical interventions have failed. 1

Initial Assessment and Conservative Management

1. First-line treatment options:

   • Offloading devices to reduce pressure on the affected metatarsal head
   • Non-removable knee-high offloading device (total contact cast or non-removable walker) for optimal pressure relief 1
   • Removable knee-high or ankle-high offloading device if non-removable devices are contraindicated 1
   • Felted foam in combination with appropriate footwear if offloading devices are unavailable 1

2. Additional conservative measures:

   • Appropriate footwear modifications (wide toe box, rocker-bottom soles)
   • Custom orthotic devices
   • Debridement of any associated ulceration or callus formation

Surgical Management Algorithm

When conservative treatment fails, surgical intervention should be considered based on the following criteria:

1. For metatarsal head calcification with ulceration:

   • Metatarsal head (MTH) resection combined with an offloading device is indicated 1
   • This approach shows moderate increases in ulcer healing (RR 1.33) and sustained healing (RR 1.21) 1
   • Significant reductions in infections (RR 0.55) and amputations (RR 0.68) have been observed 1

2. For metatarsal head calcification with osteomyelitis or joint infection:

   • MTH resection is strongly indicated to address both the infection and the mechanical pressure 1
   • The procedure should include removal of all infected tissue and the calcified area 1

3. For first metatarsal head involvement:

   • Consider joint arthroplasty for hallux ulcers with limited range of motion 2
   • Higher risk of undesirable effects compared to lateral metatarsal heads 1

4. For lateral metatarsal heads (2-5):

   • MTH resection is preferred due to lower risk of complications 1
   • If flexible toe deformity is present, digital flexor tenotomy may be considered 1
   • For recurrent ulceration, metatarsal osteotomy may be appropriate 1

Post-Surgical Management

1. Immediate post-operative care:

   • Non-removable offloading device for optimal wound healing
   • Regular wound assessment and debridement as needed
   • Appropriate antibiotic therapy if infection was present

2. Long-term management:

   • Custom footwear with pressure redistribution
   • Regular follow-up to monitor for transfer lesions (RR 1.50) 1
   • Gradual return to weight-bearing activities

Important Considerations and Caveats

• MTH resection may cause moderate decreases in quality of life during healing but moderate increases after healing 1
• There is a risk of developing transfer lesions to adjacent metatarsal heads after resection 1
• The first metatarsal head has higher risk of complications than lateral metatarsal heads 1
• Surgical procedures should be performed by surgeons with thorough knowledge of foot anatomy and compartments 1
• Vascular assessment should be performed before any surgical intervention 2
• Consider the biomechanical consequences of surgery to prevent an unstable foot or recurrent ulceration 1

The evidence strongly supports surgical intervention with MTH resection when conservative treatment fails, with significant improvements in healing rates and reductions in complications like infections and amputations.