1

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

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 3Avoid iatrogenic 3rdrd MTP synovitis MTP synovitis and latter IPK M-3and 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 shortening of

M-3M-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 andand IPK in many cases.

Not indicated in very osteoporotic patients)

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

10

Technic ( my Weil modification)

11

12

13

14

15

16

17

18

The toe standing proud dorsally post Weil osteotomy

19

Modified Weil + “externalexternal”taping…

20

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

21

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)

22

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

23

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

24

1. No shortening of the 1st Metatarsal post-op

Scarf

Mann

25

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

26

2. Shortening of 1st metatarsal expected post-op

27

Discussion begins…

ConclusionConclusion

28

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

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

Thank youThank you

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.