What is the recommended treatment plan for a patient with posttraumatic deformity of the 5th metatarsal, degenerative changes in the tarsometatarsal joint, and demineralized bones?

Management of Posttraumatic Deformity of the 5th Metatarsal with Degenerative Changes

For a patient with posttraumatic deformity of the 5th metatarsal, degenerative changes in the tarsometatarsal joint, and demineralized bones, the recommended treatment is surgical correction of the deformity to address the underlying biomechanical issues rather than direct fracture treatment, as this approach leads to better functional outcomes and healing.

Assessment of Current Status

• The radiographic findings indicate a healed fracture with posttraumatic deformity of the 5th metatarsal, degenerative changes in the 1st and 2nd tarsometatarsal joints, previous arthrodesis in the tarsal region, calcaneal spur, bone demineralization, and unusual calcifications in the distal soft tissues of the ankle 1, 2
• These findings suggest chronic changes with potential biomechanical alterations affecting foot function and weight distribution 3, 2

Treatment Algorithm

Step 1: Evaluate Biomechanical Impact and Functional Limitations

• Assess weight-bearing patterns and gait abnormalities that may be contributing to degenerative changes 1, 3
• Evaluate for equinovarus deformity or other foot malalignment that may be causing stress on the 5th metatarsal 4
• Determine the extent of functional limitation and pain during activities 5

Step 2: Consider Surgical Intervention Based on Severity

• For mild to moderate degenerative changes with minimal functional limitation:

  • Conservative management with custom orthotic devices to redistribute pressure 1
  • Appropriate footwear modifications to accommodate deformity 1

• For moderate to severe degenerative changes with significant functional limitation:

  • Surgical correction of the underlying deformity is indicated 1, 4
  • Correction of foot alignment to achieve a plantigrade foot position rather than direct fracture site intervention 4

Step 3: Surgical Options

• For isolated 5th metatarsal deformity:

  • Corrective osteotomy across the former fracture site to restore normal anatomy 2
  • Internal fixation with plates or screws to maintain correction 2

• For degenerative changes in the tarsometatarsal joints:

  • Arthrodesis (fusion) of the affected tarsometatarsal joints is recommended for severe degenerative changes 6, 5
  • This approach has shown 93% patient satisfaction with 98% union rate in long-term follow-up 5

• For cases with equinovarus deformity contributing to lateral column stress:

  • Correction of the hindfoot deformity to relieve the fifth metatarsal overload 4
  • This approach allows for fracture healing by eliminating the biomechanical stress 4

Postoperative Management

• Protected weight-bearing with appropriate offloading devices for 4-6 weeks 2
• Regular radiographic follow-up to assess healing and alignment 2
• Physical therapy to restore range of motion and strength 1
• Custom orthotics may be needed long-term to maintain proper foot mechanics 1

Potential Complications to Monitor

• Delayed union or non-union requiring additional intervention 2
• Transfer lesions or metatarsalgia due to altered weight-bearing patterns 1
• Prominent metatarsal heads causing callus formation 5
• Stress fractures of adjacent metatarsals due to load transfer 5
• Incisional neuromas 5

Special Considerations

• Bone demineralization may require additional assessment for underlying metabolic bone disease 1
• Previous arthrodesis in the tarsal region may alter biomechanics and affect surgical planning 6
• Unusual calcifications in the distal soft tissues may indicate vascular or other soft tissue pathology requiring further evaluation 1

By addressing the underlying biomechanical issues rather than focusing solely on the healed fracture, this approach provides the best opportunity for improved function, pain relief, and prevention of further degenerative changes 4, 5.