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1st Metatarsal Avascular Necrosis

Posted by Carole on 7/17/04 at 19:08 (155716)

Dear Doctor:

I am writing to request your assistance and guidance regarding a foot problem that I have. While I know that a written consultation is not acceptable medical practice, I m truly at my wit's end for some honest, straightforward information about my problem. I had a modified Keller procedure done for a 3rd-4th degree hallux rigidus on my right great toe in April 2003 by a foot specialist orthopedic surgeon. I followed the post-op regimen exactly as ordered, to include absolutely NO weight bearing until advised by the surgeon. The foot was numb, tingled and never felt 'right.' Two months later after walking had been returned to my regimen, I stress fractured the 2nd metatarsal during a slight increase in walking speed. The doctor then admitted to me that he 'may have taken too much bone'. The fracture was booted for five weeks and never relieved the pain, casted for four weeks and never relieved the pain, than booted again for five weeks and never relieved the pain. The boot caused more pain than it prevented, leaving me with knee, hip and back pain that required cortisone injections. My orthopedic surgeon and his staff have been less than helpful, other than to advise me 'back into the boot'-as if that would help!
I got a second opinion and have been given a diagnosis of metatarsal avascular necrosis. The kindly, yet evasive, physician did not give me much information about what can be done. My research on the Internet has only provided my with two patient notes that indicated this was incurable and not a fixable condition, even when they saw the Mayo Clinic. The original surgeon said he could perform a 'Z-track osteotomy' to fix the problem, but I am most hesitant to allow him the opportunity to really mess up my foot. Three months for the fitting of an orthotic has proven totally unsuccessful and the pain still persists....constantly.
I am in the process of moving to Florida when we sell our present home. I don't plan to do anything until we are settled there. But, I am in pain whenever I put weight on the foot, and it never goes away. On XRay, there is a rather large healed bone callous at the site of the 2nd metatarsal stress fracture. I wear the oxford-type shoes with only very slight relief of pain. I used to walk four miles a day for fitness, and bicycle over thirty miles as well. These activities, let alone work and activities of daily living, are impossible and difficult with my foot as it is presently. Can you PLEASE ADVISE me about potential surgical procedures and/or other treatment modalities, as the doctors I have consulted appear quite aloof about my prognosis. I am truly DESPERATE, and quite depressed about the whole thing. I humbly beg for your assistance and advice, or at least information about what options I may have left. Is a toe implant an option with the presence of the osteonecrosis? Could the osteonecrosis have occurred from the surgeon's technique?(PLEASE answer that because every doctor I have been to since refuses to commit to an opinion) And finally, can you explain the Z-track osteotomy procedure for me? Would it help?
I thank you so very much for taking the time to read this, and thank you in advance for any information you may send my way. Most sincerely, Carole

Re: 1st Metatarsal Avascular Necrosis

Dr. Z on 7/17/04 at 21:03 (155722)

Hi
Without examining you this is difficult but here goes. When part of the joint was removed performing the keller type procedure you lost the ability of that joint to carry its share of your body weight when walking. This is one of the down sides of the Keller procedure. So the weight moves to the second metatarsal bones. Your 2nd metatarsal bone then stress fractured do it over loading from the lack of your big toe joint to carry its share of weight. Ok. Then this fracture failed to heal and this is where you are today

Here is what you may need . A fusion of the big toe joint and a repair of the non healing 2nd metatarsal bone with possible bone grafting of this fracture.
Without an x-ray and or examination very hard to give a specific plan but I hope that you at least understand the weight load transfer to your 2nd metatarsal bone from the lack of the first big to joint to carry weight due to the keller type procedure

Re: 1st Metatarsal Avascular Necrosis

Ed Davis, DPM on 7/18/04 at 00:28 (155731)

Carole:
The Keller procedure is not a good choice for hallux rigidus except for very sedentary elderly people because it leaves the big toe joint dysfunctional, transferring weight to the second metatarsal.

Unfortunately, finding a fix is not always that simple. First, we would need to know if the second metatarsal is recovered/recovering; how bad the aseptic necrosis is. Also, it still may be possible to salvage the Keller procedure with an implant that could restore function to the big toe joint.
Ed

Re: 1st Metatarsal Avascular Necrosis

Carole on 7/18/04 at 12:27 (155757)

Dear Dr. Z.
THANKS so much for the prompt reply! I am aware of the 2nd metatarsal overload diagnosis, and I do understand the weight load transfer. I thought I ws doing the right thing when I specifically went to this foot specialist-orthopedist surgeon, who knew full well that I work on my feet for a living(I'm a non-practicing RN who works as a flight attendant now) I would think he would have known up front that the modifed Keller procedure was not good for me-at least, that's why I went to him-for his knowledge of these things!?! Anyway, this same surgeon, when I last saw him told me the fracture was 'healed' as of last September 2003. Please don't spare any of the gory details, but what does this fusion/bone graft entail for me? Would a toe implant help? Will I be able to walk and work without pain? Is it possible that I will be able to long-distance walk and bicycle again someday? Or is it more probable that this is as good as it will get? I am still too young to be out to pasture, and I cannot fathom having to live this way for another thirty years! Thanks again for your reply! Most sincerely, Carole

Re: 1st Metatarsal Avascular Necrosis

Dr. Z on 7/18/04 at 12:35 (155758)

Hi
You ask very good questions. Here is another factor that could and probaby contributed to your current problem. The 2nd metataral bone is too long to start with. If this is the case then resection of the non healing bone and internal fixation could resolve the problem. Now if there is severe shortness of the first met then a bone graft either from the hip , or cadavar with internal fixation is needed. This is a very long post operative healing procedure 12 weeks plus in cast and possible non-weight bearing,
Where do you live? I may be able to refer or someone on this board may be able to refer to someone for an evaluation

Re: 1st Metatarsal Avascular Necrosis

Carole on 7/18/04 at 12:48 (155759)

Dear Dr. Ed, THANKS for your prompt reply, also! Alas, I am NOT a sedentary elderly person. I am truly shocked that the orthopedic foot specialist did not recognize that I am very youthful and active for being in my early 50's, fitness walked four miles at a time, was a non-practicing RN and still currently employed as an active flight attendent! (Please forgive my sarcasm!) I really thought that I made all that perfectly clear when I saw him! Anyway, by his accounts and the Xray readings I saw, the stress fracture was 'healed' and had a large 'bone callous' around it as of last September 2003. The 2nd opinion doctor I just saw this past wek was very non-commital; He just stated that 'this would be a long, drawn out thing' when he evasively referred to the repair. He gave me no specifics, just the 'long, drawn out' comment. I am hopeful that an implant may help. And I will pose the same questions to you as I did to Dr. Z's reply, in that, is it possible that I can someday hope to resume my long-distance walking and bicycling with a fusion, an implant or whatever the repair may entail? What are the limitations I should expect? Will look forward to your reply, and once again, THANKS for your answer! Most sincerely, Carole

Re: 1st Metatarsal Avascular Necrosis

Carole on 7/18/04 at 13:06 (155760)

HI & thanks again! I live in the Cincinnati area now, but a move to Orlando, Florida is in the works as we speak. Right now, it is out of the question for me to clean and show our house while it is on the market with a cast on my foot. I have LOTS of steps in the house, and that presents a major problem. The 2nd metatarsal is extremely long and pushing the third metatarsal diagonally(is that how to correctly describe it?), and the 1st metatarsal is easily over 1/2 inch shorter than the the 2nd. (It was NOT that way preop.) The 1st metatarsal plate is now elevated and the toe is curled such that it does not even contact the floor. I had thought about going to the Mayo Clinic in Jacksonville. The kindly and very skilled doctor I went to for a 2nd opinion referred me to an orthopedic surgeon-foot specialist that he trained in Jacksonville, also. I appreciate any and all information you may have for me! THANKS AGAIN! Have a wonderful vacation! Carole

Re: 1st Metatarsal Avascular Necrosis

Ed Davis, DPM on 7/19/04 at 09:03 (155811)

Carole:
It may be possible for you to go back to long walks. I, personally, would prefer to see a different doc than he who did the initial surgery based on what you have told us.
Ed

Re: 1st Metatarsal Avascular Necrosis

Carole on 7/19/04 at 13:03 (155837)

Dear Dr. Ed,
THANKS for your reply. I plan to get it evaulated once we get settled in Florida after the move south. I appreciate all of your info! Best regards, Carole

Re: 1st Metatarsal Avascular Necrosis

Carole on 8/07/04 at 12:39 (157152)

Dr. Z. HI & hope you had a nice vacation! I wanted to get back in touch with you about a few things regarding my avascular necrosis that were unanswered when you left on vacation. I live in the Cincinnati area now, but a move to Orlando, Florida is in the works as we speak. Right now, it is out of the question for me to clean and show our house while it is on the market with a post-op condition/cast on my foot. I have LOTS of steps in the house, and that presents a major problem. You wanted to know about my 2nd metatarsal - it is extremely long and pushing the third metatarsal diagonally(is that how to correctly describe it?). The 1st metatarsal is easily over 1/2 inch shorter than the the 2nd. (It was NOT that way preop.) The 1st metatarsal plate is now elevated and the toe is curled such that it does not even contact the floor. I had thought about going to the Mayo Clinic in Jacksonville. The kindly and very skilled doctor I went to for a 2nd opinion referred me to an orthopedic surgeon-foot specialist that he trained in Jacksonville, also. I appreciate any and all information you may have for me! Even the name of someone up to the challenge of the repair work that needs to be done and lives in either the Orlando, Tampa or Jacksonville, Florida areas. THANKS AGAIN! Carole
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