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

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Presentation on theme: "1 Lesser metatarsal problems in Hallux valgus : planning before surgery planning before surgery COFAS-COA-Winnipeg 2003 André Perreault, private practice,"— Presentation transcript:

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

2 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 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 4 Factors in decision making: M-2 Osteotomy  Long 2nd metatarsal  Hammer toe  Rigidity  Shortening osteotomy M-2  L ook at M-3… Donnatello

5 5 Factors in decision making: M-3 osteotomy  Length difference 2 nd - 3 rd : Small 3 rd - 4 th : Big  Hammer toes (MTP sub-luxation)  Rigidity  Avoid iatrogenic 3 rd MTP synovitis and latter IPK M-3 and latter IPK M-3 Donnatello

6 6 Long 2 nd & 3 rd 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 shortening of M-3 …and needed… shortening of M-3

7 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 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 9 Weil: My modification  A complete removal of 2 to 3 mm slice  At an angle of 15 to 20 ° and  Can correct sub-luxation MTP and IPK in many cases. Not indicated in very osteoporotic patients) All healed, except ~ 1 % ( screw loosening or fracture)

10 10 Technic ( my Weil modification)

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18 18 The toe standing proud dorsally post Weil osteotomy

19 19 external Modified Weil + “external”taping…

20 20 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

21 21 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)

22 22 Girdlestone-Taylor transfer  FDL transect distal  Transfer to dorsum Of P-1 on the extensorsAdvantage: Patient prefer toe on the groundDisadvantage: Might add some stiffness

23 23 What about the 4 th 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

24 24 1. No shortening of the 1 st Metatarsal post-op Scarf Mann

25 25 If no shortening of the1 st metatarsal expected post-op  Not rigid  No length difference (metatarsal cascade)  No early signs of sub-luxation  Then, no surgery of lesser metatarsals needed

26 26 2. Shortening of 1 st metatarsal expected post-op

27 27 Discussion begins… Conclusion

28 28 Conclusion  The importance of planning the management of the lesser metatarsal at the 1 st 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

29 29 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.

30 30 Thank you

31 31 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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