[Anatomical reconstruction of malunited metatarsals and adjacent joints]

Malunited fractures of the metatarsals seldom need correction because the adjacent joints proximally and distally are not axially loaded but they may cause significant pain when a subcapital fracture is malunited too far in a plantar direction.

Even if a metatarsal head is malunited too dorsally the neighboring head signals transfer metatarsalgia. Therefore, reorientation osteotomy with the intraoperative help of a minidistractor and stable fixation with a small locking plate is needed. Painful nonunion, especially of the proximal fifth metatarsal needs improvement of the biology (e.g. autogenous bone graft) and of the biomechanics (e.g. stable osteosynthesis) if for example pulsed ultrasound treatment fails.

The importance of these small foot joints is illustrated by reopening the iatrogenically fused metatarso-cuboidal joint and making a new joint by interposition of crural fascia being crucial for a pain-free and fully functioning foot. The special biomechanics of the first ray is stressed by the secondary reconstruction of the first metatarsal showing a huge bony defect and poor surrounding soft tissues by performing callus distraction.