1. Lesser metatarsal problems in Hallux valgus :
planning before surgery
COFAS-COA-Winnipeg 2003
André Perreault, private 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 3rd MTP synovitis
and 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 M-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 and IPK in many cases.
Not indicated in very osteoporotic patients)
All healed, except ~ 1 % ( screw loosening or fracture)

10. Technic ( my Weil modification)

18. The toe standing proud dorsally post Weil osteotomy

19. Modified Weil + “external”taping…

20. 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. 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. 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

23. 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!

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

25. 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

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

27. Discussion begins…
Conclusion

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 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. 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 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.