Presentation on theme: "Lesser metatarsal problems in Hallux valgus :"— Presentation transcript:
1 Lesser metatarsal problems in Hallux valgus : planning before surgeryCOFAS-COA-Winnipeg 2003André Perreault, private practice, Montréal
2 Avoiding 2 or 3 or more stages surgery Avoiding: Chart review:1998 1st metatarsal osteotomy for H. Valgus1999 M-2 shortening osteotomy2000 M-3 shortening osteotomy2001 M-4 elevation osteotomy
3 The lesser metatarsals …their expected evolution after bunion surgery Should be addressed …at the first surgery if possibleThese 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 metatarsalHammer toeRigidityShortening osteotomy M-2Look at M-3…Donnatello
6 Long 2nd & 3rd metatarsal, rigid foot M-2 = M-3 >> M-4Not appreciate this :After shortening of M-2 : patient developed with time :M-3 synovitisM-3 IPK…and needed… shortening of M-3
7 Classical Weil osteotomy Osteotomy parallel to the sole of the footEx.: 5 mm shortening =2 mm plantar displacementThe 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° cut5 mm shortening =0.8 mm plantar displacementThe 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 and IPK in many cases.Not indicated in very osteoporotic patients)All healed, except ~ 1 % ( screw loosening or fracture)
20 But…some need “ internal” taping Difficulty to rely on the position of the toe after a Weiltoe position in O.R. may look goodBut with time: MTP HyperextensionPIP Flexion
21 Some need a “ internal” taping… Chronic sub-luxation at MTPFirst: Extensor lengthening and extensive capsulotomyThe toe slightly above the others:Then: tendon transfer Flexor to Extensor(Girdlestone-Taylor)
22 Girdlestone-Taylor transfer FDL transect distalTransfer to dorsumOf P-1 on the extensorsAdvantage:Patient prefer toe on the groundDisadvantage:Might add some stiffness
23 What about the 4th metatarsal… …VersaillesRigidity more than LengthMore plantar-flex M-4 than a long M-4chevron vertical sliding up than a Weil osteotomyIf you fell it proud plantar ward after M-3 osteotomy: Better do it!
24 1. No shortening of the 1st Metatarsal post-op ScarfMann
25 If no shortening of the1st metatarsal expected post-op Not rigidNo length difference (metatarsal cascade)No early signs of sub-luxationThen, no surgery of lesser metatarsals needed
26 2. Shortening of 1st metatarsal expected post-op
28 Conclusion Metatarsal relative length MTP sub-luxation (early changes) The importance of planning the management of the lesser metatarsal at the 1st surgery for Hallux valgusMetatarsal relative lengthMTP sub-luxation (early changes)RigidityM-2 > M-1: Add a shortening osteotomy of M-2M-2 = M-3 >>M-4: Shortening Osteotomy M2-3
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.
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.