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## Complete Summary

#### GUIDELINE TITLE

Metatarsalgia/intractable plantar keratosis/Tailor\'s bunion.

#### BIBLIOGRAPHIC SOURCE(S)

Academy of Ambulatory Foot and Ankle Surgery. Metatarsalgia/intractable
plantar keratosis/Tailor\'s bunion. Philadelphia (PA): Academy of
Ambulatory Foot and Ankle Surgery; 2003. 6 p. \[26 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Academy of Ambulatory Foot
and Ankle Surgery. Metatarsalgia/intractable plantar keratosis/Tailor\'s
bunion. Philadelphia (PA): Academy of Ambulatory Foot and Ankle Surgery;
2000. 13 p.

The guideline is reviewed and updated twice a year as needed (in May and
October).

### \*\* REGULATORY ALERT \*\*

#### FDA WARNING/REGULATORY ALERT

**Note from the National Guideline Clearinghouse**: This guideline
references a drug(s) for which important revised regulatory information
has been released.

On April 7, 2005, after concluding that the overall risk versus benefit
profile is unfavorable, the FDA requested that Pfizer, Inc voluntarily
withdraw Bextra (valdecoxib) from the market. The FDA also asked
manufacturers of all marketed prescription nonsteroidal
anti-inflammatory drugs (NSAIDs), including Celebrex (celecoxib), a
COX-2 selective NSAID, to revise the labeling (package insert) for their
products to include a boxed warning and a Medication Guide. Finally, FDA
asked manufacturers of non-prescription (over the counter \[OTC\])
NSAIDs to revise their labeling to include more specific information
about the potential gastrointestinal (GI) and cardiovascular (CV) risks,
and information to assist consumers in the safe use of the drug. See the
[FDA Web
site](http://www.fda.gov/medwatch/SAFETY/2005/safety05.htm#Bextra) for
more information.

Subsequently, on June 15, 2005, the FDA requested that sponsors of all
non-steroidal anti-inflammatory drugs (NSAID) make labeling changes to
their products. FDA recommended proposed labeling for both the
prescription and over-the-counter (OTC) NSAIDs and a medication guide
for the entire class of prescription products. All sponsors of marketed
prescription NSAIDs, including Celebrex (celecoxib), a COX-2 selective
NSAID, have been asked to revise the labeling (package insert) for their
products to include a boxed warning, highlighting the potential for
increased risk of cardiovascular (CV) events and the well described,
serious, potential life-threatening gastrointestinal (GI) bleeding
associated with their use. FDA regulation 21CFR 208 requires a
Medication Guide to be provided with each prescription that is dispensed
for products that FDA determines pose a serious and significant public
health concern. See the [FDA Web
site](http://www.fda.gov/medwatch/SAFETY/2005/safety05.htm#NSAID) for
more information.

### COMPLETE SUMMARY CONTENT

 \*\* REGULATORY ALERT \*\*\
 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

-   Metatarsalgia

-   Intractable plantar keratosis

-   Tailor\'s bunion

#### GUIDELINE CATEGORY

Diagnosis\
Treatment

#### CLINICAL SPECIALTY

Podiatry

#### INTENDED USERS

Podiatrists

#### GUIDELINE OBJECTIVE(S)

To provide recommendations for the diagnosis and treatment of
metatarsalgia, intractable plantar keratosis, and Tailor\'s bunion

#### TARGET POPULATION

Patients with metatarsalgia, intractable plantar keratosis, and
Tailor\'s bunion

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Diagnosis**

1.  History, including an evaluation of the chief complaint (nature,
    location, duration, onset, course, anything that improves or
    exacerbates, any previous treatment) and past medical
    history(medications/allergies, medical history, surgical history,
    family history, social history)

2.  Physical examination, including peripheral vascular, neurological,
    orthopedic(palpation, biomechanical/gait analysis, range of motion),
    and dermatological exams

3.  Diagnostic procedures, including radiographic examination,
    laboratory tests, additional tests (nerve conduction studies,
    electromyography \[EMG\], noninvasive vascular testing)

**Treatment**

1.  Nonsurgical treatments, including debridement, padding, shoe
    modifications, oral anti-inflammatory medications (NSAIDs),
    anti-inflammatory injectables, orthotics

2.  Surgical treatments, including metatarsal osteotomy (percutaneous,
    transverse, \"V\" shaped, or bi- or tri- plane, partial or \"through
    and through\"), excision of all or part of a metatarsal head and/or
    shaft, intramedullary decompression

3.  Postoperative management, including x-rays, foot gear, and orthotics

#### MAJOR OUTCOMES CONSIDERED

Not stated

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The guideline development process began with a thorough MEDLINE search
as well as a \"call for papers\" from the membership of the Academy of
Ambulatory Foot and Ankle Surgery at large.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not applicable

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Drafts of the guidelines were reviewed in detail by each member of the
Board of Trustees.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

I.  Diagnosis

    A.  History: This may include any of the following:

        1.  An evaluation of the chief complaint (including the nature,
            location, duration, onset, course, anything that improves or
            exacerbates, and any previous treatment).

        2.  The past medical history (including medications/allergies,
            medical history, surgical history, family history, and
            social history).

    B.  Physical examination: The following may be important parts of
        the appropriate examination:

        1.  Peripheral vascular

        2.  Neurological

        3.  Orthopedic (involvement may be ascertained by examining the
            foot in either the weight bearing or non-weight bearing
            positions)

            a.  Palpation

            b.  Range of motion

            c.  Biomechanical/gait analysis

        4.  Dermatological (presence of lesions or hyperkeratoses).

II. Diagnostic Procedures

    A.  Radiographic examination: X-rays should be taken. They may be
        used to evaluate the type of deformity as well as other factors.
        X-rays may be weight bearing, partial weight bearing, or
        non-weight bearing.

    B.  Laboratory tests: Not required in the nonsurgical patient,
        unless underlying factors exist (i.e., infection or inflammatory
        disease). Blood and urine tests may be indicated for the
        surgical patient at the discretion of the surgeon based on the
        patient\'s medical history.

    C.  Additional tests (nerve conduction studies, electromyography
        (EMG), noninvasive vascular testing). These studies may be
        utilized in isolated situations when deemed necessary.

III. Nonsurgical Treatment

     A.  The primary reasons for nonsurgical treatment are:

         1.  Due to the patient\'s health status, surgery is
             contraindicated

         2.  The patient does not want surgery

     B.  Types of nonsurgical treatment:

         1.  Debridement

         2.  Padding

         3.  Shoe modifications

         4.  Oral anti-inflammatory medications (NSAIDs)

         5.  Anti-inflammatory injectables

         6.  Orthotics

IV. Surgical Treatment

    A.  The primary reasons for surgical treatment are:

        1.  Failure of nonsurgical treatment

        2.  Impracticality of nonsurgical treatment

        3.  The patient desires correction of a presenting deformity
            that is painful and/or causes a degree of loss of function.

        4.  The patient is informed of the procedure(s) to be performed,
            the treatment alternatives, and the reasonable risks
            involved and elects to have surgical intervention.

    B.  Site of surgery: The surgical treatment of metatarsalgia,
        intractable plantar keratosis (IPK), and Tailor\'s bunion is
        usually performed in the doctor\'s office, however, the hospital
        or an ambulatory center may also be appropriate.

    C.  Anesthesia: Local anesthesia is sufficient, unless there are
        extenuating circumstances.

    D.  Hemostasis: Absence of bleeding is not required.

    E.  Surgical preparation: aseptic preparation (\"usual\" aseptic
        scrub, prep, draping, and sterility).

    F.  Preoperative lab: May or may not be necessary based on the
        patient\'s past medical history and current medical status.

    G.  Prophylactic antibiotics: At the discretion of the surgeon (or
        based upon requirement: i.e., mitral valve prolapse).

    H.  Pathological analysis of surgically removed tissue: Recommended.

    I.  Bilateral or multiple surgery: May be performed at the same
        surgical session, or in different surgical sessions.

V.  Surgical Procedures for the Correction of
    Metatarsalgia/IPK/Tailor\'s Bunion

> Procedures may be performed as isolated situations or in conjunction
> with other procedures.

A.  Metatarsal osteotomy may be:

    1.  Percutaneous

    2.  Transverse, \"V\" shaped, or bi- or tri-plane

    3.  Partial or \"through and through\"

B.  Excision of all or part of a metatarsal head and/or shaft may be
    performed at appropriate times to treat these conditions.

C.  Intramedullary decompression (IMDC)

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VI. Fixation

> Fixation may be via internal, percutaneous, or external means such as
> casts, splints, surgical shoes, or adhesive forms of dressings.
> Internal fixation is generally not required and is at the discretion
> of the surgeon.

VII. Postoperative Management

> The patient may ambulate during the recovery period. X-rays should be
> taken postoperatively and may be taken thereafter to access the
> healing. Postoperative foot gear may include a surgical shoe or other
> form of restrictive footwear. Generally, a surgical dressing is
> applied in the immediate postoperative period. This is modified with
> time and the postoperative course. The return to a normal shoe is
> based upon the procedure(s) performed and the postoperative course of
> the individual patient. Orthotics may be useful postoperatively.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is not specifically stated for each
recommendation.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Treatment may relieve or reduce pain, reduce the deformity, eliminate
lesions (or reduce severity), and arrest progression of deformity.

#### POTENTIAL HARMS

**Postoperative Complications**

-   Edema

-   Recurrence/regrowth

-   Pain

-   Numbness

-   Stiffness

-   Shortening of digits/metatarsals

-   Malposition

-   Nonunion

-   Delayed union

-   Transfer lesions

-   Vascular complications

-   Reflex sympathetic dystrophy

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Living with Illness

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Academy of Ambulatory Foot and Ankle Surgery. Metatarsalgia/intractable
plantar keratosis/Tailor\'s bunion. Philadelphia (PA): Academy of
Ambulatory Foot and Ankle Surgery; 2003. 6 p. \[26 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2000 (revised 2003 Sep)

#### GUIDELINE DEVELOPER(S)

Academy of Ambulatory Foot and Ankle Surgery - Medical Specialty Society

#### SOURCE(S) OF FUNDING

Academy of Ambulatory Foot and Ankle Surgery (AAFAS)

#### GUIDELINE COMMITTEE

Preferred Practice Guidelines Committee

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

The committee consisted of five (5) members who were board certified,
had a minimum of ten (10) years of clinical practice experience, and a
minimum of five (5) years of teaching experience.

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Academy of Ambulatory Foot
and Ankle Surgery. Metatarsalgia/intractable plantar keratosis/Tailor\'s
bunion. Philadelphia (PA): Academy of Ambulatory Foot and Ankle Surgery;
2000. 13 p.

The guideline is reviewed and updated twice a year as needed (in May and
October).

#### GUIDELINE AVAILABILITY

Electronic copies: Not available at this time.

Print copies: Available from the Academy of Ambulatory Foot and Ankle
Surgery (AAFAS) (formerly the Academy of Ambulatory Foot Surgery), 1601
Walnut Street, Suite 1005, Philadelphia, PA 19102; Web site,
[www.academy-afs.org](http://www.academy-afs.org/).

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on October 12, 2000. The information
was verified by the guideline developer as of December 8, 2000. This
summary was updated by ECRI on December 19, 2003. The information was
verified by the guideline developer on December 29, 2003. This summary
was updated on May 3, 2005 following the withdrawal of Bextra
(valdecoxib) from the market and the release of heightened warnings for
Celebrex (celecoxib) and other nonselective nonsteroidal
anti-inflammatory drugs (NSAIDs). This summary was updated by ECRI on
June 16, 2005, following the U.S. Food and Drug Administration advisory
on COX-2 selective and non-selective non-steroidal anti-inflammatory
drugs (NSAIDs)./p\>

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is
copyrighted by the guideline developer.

### DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008