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Lesser metatarsal problems in Hallux valgus : planning before surgery. COFAS-COA-Winnipeg 2003. André Perreault, private practice, Montréal. Avoiding 2 or 3 or more stages surgery. Avoiding: Chart review: 1998 1st metatarsal osteotomy for H. Valgus

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Lesser metatarsal problems in Hallux valgus :

planning before surgery

COFAS-COA-Winnipeg 2003

André Perreault, private practice, Montréal

avoiding 2 or 3 or more stages surgery
Avoiding 2 or 3 or more stages surgery
  • Avoiding: Chart review:
  • 1998 1st metatarsal osteotomy for H. Valgus
  • 1999 M-2 shortening osteotomy
  • 2000 M-3 shortening osteotomy
  • 2001 M-4 elevation osteotomy
the lesser metatarsals their expected evolution after bunion surgery
The lesser metatarsals…their expected evolution after bunion surgery
  • Should be addressed …at the first surgery if possible
  • These common decisions are by far more important than the technic to correct the Hallux valgus
factors in decision making m 2 osteotomy
Factors in decision making: M-2 Osteotomy
  • Long 2nd metatarsal
  • Hammer toe
  • Rigidity
  • Shortening osteotomy M-2
  • Look at M-3…

Donnatello

factors in decision making m 3 osteotomy
Factors in decision making: M-3 osteotomy
  • Length difference 2nd - 3rd : Small

3rd - 4th : Big

  • Hammer toes (MTP sub-luxation)
  • Rigidity
  • Avoid iatrogenic 3rd MTP synovitis

and latter IPK M-3

Donnatello

long 2 nd 3 rd metatarsal rigid foot
Long 2nd & 3rd metatarsal, rigid foot
  • M-2 = M-3 >> M-4
  • Not appreciate this :

After shortening of M-2 : patient developed with time :

M-3 synovitis

M-3 IPK

…and needed… shortening of M-3

classical weil osteotomy
Classical Weil osteotomy
  • Osteotomy parallel to the sole of the foot
  • Ex.: 5 mm shortening =

2 mm plantar displacement

  • The problem in rigid foot with IPK, tend to displace the “BUMP” more proximal
weil myerson s modification
Weil: Myerson’s modification
  • With a wedge resection above the 25° cut
  • 5 mm shortening =

0.8 mm plantar displacement

The problem: the toe is higher and do not touch the ground

(but: no functional signification; cosmetic concern only)

weil my modification
Weil: My modification
  • A complete removal of 2 to 3 mm slice
  • At an angle of 15 to 20 °
  • Can correct sub-luxation MTP andIPK in many cases.

Not indicated in very osteoporotic patients)

All healed, except ~ 1 % ( screw loosening or fracture)

but some need internal taping
But…some need “ internal” taping
  • Difficulty to rely on the position of the toe after a Weil
  • toe position in O.R. may look good
  • But with time: MTP Hyperextension

PIP Flexion

some need a internal taping
Some need a “ internal” taping…
  • Chronic sub-luxation at MTP
  • First: Extensor lengthening and extensive capsulotomy
  • The toe slightly above the others:
  • Then:tendon transfer Flexor to Extensor

(Girdlestone-Taylor)

girdlestone taylor transfer
Girdlestone-Taylor transfer
  • FDL transect distal
  • Transfer to dorsum

Of P-1 on the extensors

Advantage:

Patient prefer toe on the ground

Disadvantage:

Might add some stiffness

what about the 4 th metatarsal
What about the 4th metatarsal…

…Versailles

  • Rigidity more than Length
  • More plantar-flex M-4 than a long M-4
  • chevron vertical sliding up than a Weil osteotomy
  • If you fell it proud plantar ward after M-3 osteotomy: Better do it!
if no shortening of the1 st metatarsal expected post op
If no shortening of the1st metatarsal expected post-op
  • Not rigid
  • No length difference (metatarsal cascade)
  • No early signs of sub-luxation
  • Then, no surgery of lesser metatarsals needed
conclusion
Conclusion
  • The importance of planning the management of the lesser metatarsal at the 1st surgery for Hallux valgus
        • Metatarsal relative length
        • MTP sub-luxation (early changes)
        • Rigidity
  • M-2 > M-1:Add a shortening osteotomy of M-2
  • M-2 = M-3 >>M-4:Shortening Osteotomy M2-3
conclusion29
Conclusion
  • Rigid M-4 plantar-flex: Sliding up Chevron
  • For M2-3:I prefer my modification of Weil osteotomy that allow shortening with almost no plantar displacement.
  • I often add a tendinous transfer of Girdlestone-Taylor with a PIP fusion for chronic cases, in order to avoid the toe standing proud, without touching the ground. Plus extensor tendon lengthening and MTP capsulotomy.
in very severe cases of chronic complete mtp luxation
In very severe cases of chronic complete MTP luxation
  • Very rigid, the soft tissues are usually so contracted that Weil osteotomy is impossible.
  • Most of time proximal P-1 excision is needed, plus either some metatarsal osteotomies or metatarsal head excision.