83: Salvage of Metatarsal Lengthening Nonunion with Structural Iliac Crest Autograft

Fig. 1

Photograph shows the lengthening external fixator used. A proximal pin was removed for loosening. The distal pins attempted to distract the first MTP joint. The arrow indicates a draining sinus

Fig. 2

(a, b) AP and lateral radiographs show the midshaft bone defect at the lengthening site. The fixation is weak and there is no discernable MTP joint. An antibiotic bead is seen in the defect

3 Preoperative Problem List

Nonunion of the first metatarsal with a bone defect

Previous infection of the regenerate

Unstable fixation

Post-traumatic arthritis of the first MTP joint

4 Treatment Strategy

A staged treatment approach was utilized:

The external fixator was removed, the nonunion site was debrided through the draining medial incision, cultures were taken, and a large antibiotic cement bead was placed into the defect.

A bicortical iliac crest bone grafting was performed once the wound closed and there were no signs of infection. A stable external fixator was placed spanning the defect site and an axial wire was added for stability.

5 Basic Principles

The basic principles for the treatment of an infected nonunion apply to this situation: eradicate the infection with debridement and local and systemic antibiotics, autologous bone grafting v bone transport to fill the defect, stable fixation to allow union. The preservation of length was an important goal in this case. The patient had already sacrificed much effort toward obtaining a longer metatarsal and wanted to maintain that length. Another option was to shorten the metatarsal back to the pre-lengthening position and compress until union.

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