Severe Forefoot Disorders
In the majority of severe cases of forefoot deformities it is possible to carry out successful
joint preserving surgery instead of traditional joint sacrificing procedures.
Fig. 39a1. Severe forefoot disorders – Current radiological and clinical aspects.
Fig. 39a2. Severe forefoot disorders. Some current procedures which can be avoided now.
1. Keller procedure or first MTP prosthesis, PIP resection arthroplasty on the lesser toes.
2. “Systematic” first MTP fusion and lesser metatarsal resection (we perform these procedures but in limited indications).
3. Disorders resulting from anarchic metatarsal head resections.
4. Among these procedures, we have to distinguish the Regnauld’s technique (that we made before the Weil osteotomy), which can provide good result while preserving the lesser metatarsal heads (enclavement). However it is unpredictable concerning the blood supply of the metatarsal heads, and on the other hand the shortening of the first metatarsal was not performed (only the first phalanx shortening). So this procedure was indicated above all in case of index minus metatarsal formula.
Ten years ago, we were perplexed when a patient came in consultation with painful severe fore- foot disorders. Now, we are not only embarras- sed, but we can offer our patients joint preser- vative solutions, with a painless postoperative period and notable functional recovery. So, faced with the anxiety of such patients, often already operated several times, we can now bring a peaceful and confident glance for both reassure the patients and treat correctly its severe forefoot disorders.
Our decisive case was performed in October 1993 (Fig. 39a3). We were surprised when we observed the good results, first immediately in the postoperative period, then year by year and at last with six years follow-up. This case encou- raged us to continue in this therapeutic way.
The key to the severe forefoot disorders treat- ment is certainly the longitudinal decompres- sion provided by the large and harmonized metatarsal shortening.
The amount of metatarsal shortening is assessed clinically and radiologically.
Clinically, this is above all reliable in the first ray, notably by the observation of the first
MTP passive dorsal flexion with a maneuver trying to correct the intermetatarsal angle and the hallux valgus deformity. In case of loss of MTP dorsal flexion, the first metatarsal shorte- ning is indicated: However, a more accurate assessment is made intraoperatively after MTP lateral release and M1 medial approach. We usually observed that 1/2 cm M1 shortening increases the MTP dorsal flexion up to 30°.
Radiographically, we observed that both good correction of the hallux valgus deformity and improvement of the MTP are obtained when shortening is up to the X-ray level of the most proximal part of the first phalanx: It is the ms point noted in many pictures of this book.
In cases where the shortening is less, the result is insufficient. This is reliable whatever the consi- dered ray (first ray, lesser rays). This may be assessed on dorso-plantar X-ray views but also in the medial oblique view. This ms point is useful for the assessment of metatarsal shorte- ning in the following cases: MTP dislocation, severe hammer or claw toes, or lateral deviation such as lateral wind-swept toes deformities as well as advanced hallux valgus deformity.
Fig. 39a3. Our deciding case to preserve MTP joints in severe forefoot disorders.
In October 1993, I attempted for the first time to correct this severe forefoot disorder, while preserving the MTP joints, thanks to the shortening of the metatarsals (scarf and Weil osteotomies). In this picture we show the results six years after this procedure (October 1999). This case was deciding to carry on such joint preservation in severe forefoot disorders.
We observe that this result is obtained with the following amount of shortening: the remaining first metatarsal lenght is located on the basis of the proximal phalanx of the great toe in the P reoperative X-ray:
this is the ms (Metatarsal Shortening) point.
In this case, we observed that the hallux valgus correction is stable as well as the correction of the MTP dislocation of the lesser rays. Nevertheless, we also observe that the second metatarsal remains too long:
Secondary we performed PIP resection arthroplasty on the second toe, which is not a good procedure.
We also observe that the great toe remains too long: Now we avoid these problems.
Fig. 39b1. Severe forefoot disorders – Longitudinal decompression by shortening of the metatarsals: Surgical principles.
1, 2, 3. First metatarsal shortening by M scarf osteotomy with the Maestro technique, which increases the fragmental contact and preserves the TP lateral ligament. This results in longitudinal decompression of the MTP joint (3) which allows the correction of both severe hallux valgus and impaired MTP joint.
4, 5. Weil lesser metatarsal osteotomy provides a predictable and reliable shortening of the metatarsals while preserving the head with its blood supply. The resulting longitudinal decompression allows relief of metatarsalgia as well as correction of any toe deformity.
6, 7. In MTP dislocation, the proximal sliding has to be as large as the metatarsal phalangeal over ridding (ms point).
We observe that the best results were obtained with these two conditions: Large and harmonized shortening of the metatarsals.
Fig. 39b2a. Severe forefoot disorders – Management when the lesser rays are the most impaired.
1. In this case, the most impaired or deformed ray is the second one.
2. So we focus the surgery on this ray (it is the most common impaired ray): Shortening as far as to obtain the correction of the MTP dislocation (Weil osteotomy).
3, 4. Then harmonizing the other metatarsals (in this case particularly the first one).
Fig. 39b2b. Severe forefoot disorders – Management when the first ray is the most impaired.
1, 2. The amount of shortening (ms point) is determined from the first metatarsal of the left foot, but is applied on contra-lateral foot: We observe that this shortening, which allows preservation of the MTP joint, is finally almost the same as for the MTP fusion of this joint; good result with this amount of shortening.
3, 4. Recovering of the MTP dorsal flexion needs to shorten the first metatarsal.
Postoperative Aspects
Certainly, surgery of severe forefoot disorders is more invasive than for single bunion. Two days at the hospital are recommended instead of one day. However, we observe that both postopera-
tive edema and pain are minimum, but on the condition to perform a large shortening of the metatarsals.
This large shortening is also a solution to decrease or to avoid the Reflex Sympathetic Syndrome (RSDS).
Fig. 39b3. Severe forefoot disorders – Postoperative aspects.
1. Elevation of the foot is a rule to diminish edema. So, in this case, a minimum of “two days surgery” instead of “one day surgery”.
2. Toes strapping and self-training are also essential.
3. With large metatarsal shortening, no pain and minimum swelling of the foot in postoperative period.
4. Complex Regional Pain Syndrome (CRPS) occurs more often than for less invasive surgery, but it is usually relieved by Thyrocalcitonin injections without retaining too much stiffness. However, CRPS is now much more seldom since we make a larger shortening of the metatarsals.
Application to the Main Types of Forefoot Severe Disorders
In the following plates, we find the application of this metatarsal shortening procedure in the
main severe static troubles of the forefoot: for example, advanced and iatrogenic hallux valgus, MTP dislocation or severe metatarsalgia and claw toes.
Fig. 39c1a. Severe forefoot disorders – Advanced hallux valgus deformity.
1, 2, 3. There is no more problem to obtain a reliable correction whatever the deformity but, once again, with large shortening of the metatarsals. (1, 2. Same case). These three cases: two years follow-up.
Fig. 39c1b. Severe forefoot disorders – Failed bunionectomy: Joint preservative treatment.
1, 2. It is easy to correct this failed bunionectomy with the shortening of the metatarsals.
3, 4. Other example of severe failed bunionectomy; ms: Metatarsal shortening level.
Fig. 39c1c. Severe forefoot disorders – Failed bunionectomy: Overcorrection.
1, 2. Overcorrection is also well corrected, with joint preservation, but we have to take care to the possibility of first metatarsal head necrosis (rare when the metatarsal shortening is performed).
3, 4. In severe and long-lasting overcorrection, the most reliable treatment is first MTP joint fusion and Weil osteotomy on the lesser metatarsals.
Fig. 39c1d. Severe forefoot disorders – Failed bunionectomy: After Keller procedure.
Articular preservation 1-2 in this case where there is sufficient active MTP motion and not too much pain, articular preservation by scarf osteotomy (and combined Weil osteotomy if necessary) is a good solution.
MTP fusion and weil osteotomy of the lesser rays: it is an excellent solution in the following cases : 3-4 after Keller procedure followed by loss of great toe ground contact. 5-6 Keller followed by painful and stiff MTP joint and lesser rays metatarsal.
Fig. 39c2. Severe forefoot disorders – Some examples of correction with joint preservation.
1, 2. MTP dislocation: Correction with complete joint preservation thanks to harmonized metatarsal shortening.
3, 4. Medial wind-swept toes: Same remarks.
5, 6. Metatarsalgia relieving and good function.
Fig. 39c3a. Severe forefoot disorders – Limits of joint preservation: Trophic troubles?
Trophic troubles are not a limit for joint preservation in severe forefoot disorder, but once again on the condition to make a large shortening of the metatarsals.
Fig. 39c3b. Severe forefoot disorders – Limits of correction with joint preservation: Some examples.
1, 2. Preoperative and one year follow-up: All joints preserved, except second ray (there was no more head!).
Note the M1 shortening up to the lateral basal location of the first phalanx (ms point).
3. Preoperative and two years follow-up rheumatoid foot: Just one metatarsal head resection.
4. In this case, with dislocated first MTP joint with a first metatarsal which is already short, fusion of the first MTP joint and Weil osteotomy on the lesser metatarsals.
Limits, Problems
and Long-Term Result
of Such Joint Preservative Surgery
Our questions were: Are trophic troubles a real contraindication to this joint preservative sur- gery? What about the foot length diminution?
Certainly, joint preservation has limits, but these limits are now far away. So that we still
perform the traditional first MTP fusion and metatarsal head resection, but only when it is necessary – i.e. rarely. On the last feet with severe deformity operated on, the average rate was:
Head preservation 88%, head resection 12%.
At last, we show some examples of long-term results: Our follow-up is not more than seven years, but until now we don’t observe any deterioration of the result with such a follow-up;
this emphasizes the reliability of this procedure.
Fig. 39c4. Severe forefoot disorders – The relative shortening of the foot.
Regarding the footwear, we have to remark that the shortening of the first ray is by far the most significant one (lesser rays shortening does not change the shoe size).
1, 2. The shortening of the first metatarsal (m) can be larger than the first phalanx shortening (p): But how compensate this shortening on the other foot?
3, 4. Sometimes the shortening of the great toe first phalanx is sufficient.
5, 6. In this case, the required shortening was large, focused on the second ray MTP dislocation (ms) but the patient did not withstand the shortening of the right foot: she lost her court shoes!
7. So we were obliged to secondarily shorten this foot by shortening of the metatarsals.
8. One year follow-up: Good result, the patient continues to wear her court shoes. This emphasizes the harmonized metatarsal shortening as a harmless procedure.
Fig. 39c5a. Severe forefoot disorders – Long-term result: One example of five years follow-up of bilateral case of joint preservative surgery.
The shortening of the five metatarsals significantly widen the indications of joint preservation in the treatment of severe forefoot disorders.
Fig. 39c5b. Severe forefoot disorders – Long-term result: Articular preservation in failed bunionectomy.
Another example: three years follow-up. The five metatarsals shortening with preservation of the toes length leave a foot which looks well and is able to fit elegant shoes.
