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Lesser metatarsal problems in Hallux valgus : planning before surgery

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

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  1. Lesser metatarsal problems in Hallux valgus : planning before surgery COFAS-COA-Winnipeg 2003 André Perreault, private practice, Montréal

  2. 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

  3. 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

  4. Factors in decision making: M-2 Osteotomy • Long 2nd metatarsal • Hammer toe • Rigidity • Shortening osteotomy M-2 • Look at M-3… Donnatello

  5. 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

  6. 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

  7. 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

  8. 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)

  9. 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)

  10. Technic ( my Weil modification)

  11. The toe standing proud dorsally post Weil osteotomy

  12. Modified Weil + “external”taping…

  13. 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

  14. 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)

  15. 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

  16. 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!

  17. 1. No shortening of the 1st Metatarsal post-op Scarf Mann

  18. 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

  19. 2. Shortening of 1st metatarsal expected post-op

  20. Discussion begins… Conclusion

  21. 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

  22. 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.

  23. Thank you

  24. 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.

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