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 1999 M-2 shortening osteotomy 2000 M-3 shortening osteotomy 2001 M-4 elevation osteotomy

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

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

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

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

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

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)

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)

Technic ( my Weil modification)

The toe standing proud dorsally post Weil osteotomy

Modified Weil + “external”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

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)

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

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!

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

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

2. Shortening of 1st metatarsal expected post-op

Discussion begins… Conclusion

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 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

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.

Thank you

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.