Purpose: Osteonecrosis of the metatarsal heads is a source of metatarsalgia usually triggered by local overload. The Gauthier technique, described in 1974 consists in a dorsal flexion osteotomy with cuneiform resection of the necrotic zone. Results reported in the literature have generally been limited to mid-term. We evaluated the long-term outcome.
Material and methods: We conducted a clinical and radiological review of a small homogeneous series of ten patients (nine women and one man) who presented metatarsal head necrosis (generally the third metatarsal) causing mechanical pain. In one patient, the phalangeal surface was degenerative. Eight patients had associated asymptomatic hallux valgus which was left intact. Mean follow-up was 9.5 years (27 months – 19 years).
Results: The metatarsophalangeal joint was pain free in all patients. Mean plantar flexion was 25°, extension was free with no particular limitation. Radiographically, there was no evidence of recurrent osteochondritis nor long-term degeneration. The height of the joint space (measured by comparison with the length of the lateral sesamoid) displayed a gain in all patients postoperatively.
Discussion: The Gauthier intervention has regularly provided good short- and mid-term results with restitution of a good-quality metatarsophalangeal space. There is generally however a marked limitation of dorsal flexion. This small series with long-term follow-up demonstrates that dorsal flexion tends to normalise over time and that recurrent necrosis or osteoarthritic degeneration is not a problem. This result can be explained by the reduction of joint stress due to the shorter anteroposterior effect and the elevation of the metatarsal head. Although our one case of overall joint degeneration did not worsen, this technique is probably of limited value for advanced-stage osteonecrosis since it cannot reconstitute a healthy phalangeal cartilage damaged before the operation. Surgical correction of associated deformities of the first ray should be discussed: among the eight cases of asymptomatic hallux valgus preoperatively, three remained symptom free, five worsened, and two were treated surgically.
Conclusion: The regularly satisfactory early results of the Gauthier osteotomy performed for osteonecrosis of the metatarsal head persist in the long term and improve with time in terms of joint motion, making this method a choice technique.
