When can a patient transition to a Controlled Ankle Movement (CAM) boot after fifth metatarsal head excision, pinning of the fifth Metatarsophalangeal (MTP) joint, and left foot medial sesamoidectomy?

Weight-Bearing Transition After Fifth Metatarsal Head Excision with MTP Pinning and Sesamoidectomy

Patients can transition to weight-bearing as tolerated (WBAT) in a CAM boot starting at 2 weeks postoperatively, with progressive weight-bearing advancement through 6 weeks until full weight-bearing is achieved.

Postoperative Weight-Bearing Protocol

Weeks 0-2: Non-Weight-Bearing Phase

• Strict non-weight-bearing with soft wrap and postoperative boot for the first 2 weeks 1
• Keep incision clean and dry with frequent elevation 1
• This initial period allows for soft tissue healing and early bone consolidation at surgical sites 1

Weeks 2-6: Progressive Protected Weight-Bearing in CAM Boot

• Remove sutures at 2-6 weeks and initiate progressive weight-bearing in CAM boot 1
• Week 3: 25% weight-bearing 1
• Week 4: 50% weight-bearing 1
• Week 5: 75% weight-bearing 1
• Week 6: 100% weight-bearing 1
• Use crutches during transition periods 1
• Begin ankle range-of-motion exercises and strengthening 1

Weeks 6-12: Advanced Rehabilitation

• Continue CAM boot for all weight-bearing ambulation 1
• Increase walking and physical therapy 1
• Initiate pool or treadmill activity at weeks 8-12 1
• Expect radiographic evidence of union between weeks 6-10 1

Rationale for Early Transition

The combination of procedures performed (metatarsal head excision, MTP pinning, and sesamoidectomy) allows for earlier weight-bearing compared to isolated fracture fixation because:

• Metatarsal head excision removes the primary weight-bearing surface requiring healing 2, 3
• MTP joint pinning provides immediate stability 1
• Sesamoidectomy patients typically return to activities at 11.6 weeks on average 4

CAM Boot Advantages

The CAM boot provides superior outcomes compared to hard-soled shoes for forefoot procedures:

• Faster bone healing (7.2 weeks vs 8.6 weeks) 5
• Allows controlled ankle motion while protecting the surgical site 5
• Provides adequate offloading of the forefoot 6

Critical Monitoring Points

Clinical Assessment

• Monitor for wound complications, particularly in diabetic patients who require special attention to prevent ulceration 7, 3
• Assess for pain, swelling, and signs of infection at each visit 1
• Evaluate for hallux valgus progression after medial sesamoidectomy (occurs in approximately 4% of cases) 4

Radiographic Assessment

• Obtain radiographs at 4,8,10, and 12 weeks to confirm healing 5
• Union rates for similar procedures range from 89-100% 1

Common Pitfalls to Avoid

• Do not allow immediate weight-bearing - this increases risk of hardware failure and nonunion 1
• Do not use conventional footwear instead of CAM boot during the first 6 weeks - inadequate offloading increases complication risk 2
• Do not advance weight-bearing faster than 25% per week - this protocol is established to optimize healing 1
• Avoid making the transition to regular shoes before 6 weeks - premature discontinuation of the CAM boot increases risk of transfer metatarsalgia 5

Special Considerations for Diabetic Patients

• Ensure proper fitting of the CAM boot to prevent pressure sores and ulceration 7, 3
• More frequent wound checks may be necessary 7
• Consider non-removable offloading devices if compliance is a concern 2