365 Eight Principles of Forefoot Reconstruction
Third Principle
The metatarsal parabola
The third principle is to reach a correct rela- tive length of the metatarsals – i.e. the meta- tarsal parabola (Fig. 45c1-2).
This has to be achieved not only on the dorso-plantar view, but also on the medial oblique view.
Fig. 45c1. Principle III – To reach or to respect a correct relative length of the metatarsals (metatarsal parabola). a) In the dorso-plantar view.
1. The ideal metatarsal parabola to be reached.
2. However, this parabola is also good – with a slight index minus metatarsal index and a Maestro line distally passing from the centre of the fourth metatarsal head.
3. Metatarsal parabola leading to central metatarsalgia: Second metatarsal longer than 3mm and maestro line proximally passing from the center of the fourth metatarsal.
4. Too long second metatarsal: Metatarsalgia on this ray.
5. Too long lesser metatarsals, both metatarsals index and Maestro line proximal to the fourth metatarsal head: Postoperative X-rays.
6 to 8. Excessive length of the first metatarsal has absolutely to be avoided because it results in unstable correction (under or over correction of hallux valgus), in MTP stiffness (loss of dorsal flexion), and in first ray metatarsalgia.
366 Forefoot Reconstruction
Fourth Principle
The generous shortening of the metatarsals
The fourth principle is to give more place to a generous shor tening of the metatarsals (Fig. 45d1-2-3-4), resulting in a significant widening of joint preservation.
This is certainly a point which is more difficult to assimilate because first, previous techniques of shortening were unpredictable, harmful, invasive and because surgeons generally think that the “less is the best”. In spite of this, my observations and critique of the results show clearly, strongly, obviously that the generous shortening of the metatarsals provides a pain- less, harmless, reliable and elegant solution to any severe deformity of the forefoot.
Fig. 45c2. Principle III – To reach a correct relative length of the metatarsals (metatarsal parabola). b) In the medial oblique view.
1. The medial oblique view.
2. Metatarsalgia on the third ray: Same foot on dorso-plantar view. The third metatarsal has a correct length comparatively to the second one. The Maestro line is correct. The explanation of this metatarsalgia location is provided by the medial oblique view, which shows the relative excess of length of the third metatarsal.
3. Single second metatarsal osteotomy, resulting in excessive length of the third metatarsal. The corresponding transfer metatarsalgia was relieved by a secondary Weil osteotomy.
4. Single second metatarsal well managed osteotomy: The second metatarsal remains slightly longer than the third one. There is no transfer metatarsalgia.
