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Lesser metatarsal problems in Hallux valgus :Lesser metatarsal problems in Hallux valgus : planning before surgeryplanning before surgery
COFAS-COA-Winnipeg 2003COFAS-COA-Winnipeg 2003
André Perreault, André Perreault, private practice, Montréalprivate practice, Montréal
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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
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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
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Factors in decision making: M-2 Osteotomy
Long 2nd metatarsal Hammer toe Rigidity
Shortening osteotomy M-2 Look at M-3…
Donnatello
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Factors in decision making: M-3 osteotomy
Length difference 2nd - 3rd : Small
3rd - 4th : Big
Hammer toes (MTP sub-luxation) Rigidity
Avoid iatrogenic 3Avoid iatrogenic 3rdrd MTP synovitis MTP synovitis and latter IPK M-3and latter IPK M-3
Donnatello
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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 shortening of
M-3M-3
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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
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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)
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Weil: My modification
A complete removal of 2 to 3 mm slice
At an angle of 15 to 20 ° Can correct sub-luxation
MTP andand IPK in many cases.
Not indicated in very osteoporotic patients)
All healed, except ~ 1 % ( screw loosening or fracture)
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But…some need “ internal” tapinginternal” 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
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Some need a “ internal” taping…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)
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Girdlestone-Taylor transfer
FDL transect distal Transfer to dorsumOf P-1 on the extensors
Advantage:Advantage:
Patient prefer toe on the ground
Disadvantage:Disadvantage:
Might add some stiffness
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What about the 4th metatarsal…
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!
…Versailles
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If no shortening of the1st metatarsal expected post-op
Not rigidNo length difference (metatarsal cascade)
No early signs of sub-luxation
Then, no surgery of lesser metatarsals neededThen, no surgery of lesser metatarsals needed
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Conclusion The importance of planning the management of the
lesser metatarsal at the 1st surgery for Hallux valgus
Metatarsal relative lengthMTP 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
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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.