First Principle
The post operative period
Our first principle is to make a surgery follo- wed by painless postoperative period and early functional recovery (Fig. 45a1-2): Thanks to the improvement of the surgical technique, we can be less invasive by the respect of soft tissue, by strong fixation of the osteotomies, and generally by accurate surgery respecting the forefoot architecture. Furthermore, a local, long-lasting anesthesia injection is made (ex.: naropeine).
Postoperative period is also carefully mana- ged with the foot elevated at least for two days following the surgery. The physiotherapy and the self-training are critical and need discipline from the patient which has to be strongly concerned in the successful achievement of this foot surgery.
Second Principle
Where to focus the surgery (law of the most impaired ray)
The second principle is to focus the surgery on the most affected ray, and to harmonize the foot (and the contra-lateral foot) from or around the correction of this focused ray (Fig. 45b1).
This is particularly useful when shortening of this ray (mainly metatarsal) is necessary.
Since we now have very reliable and harmless procedures to shorten the metatarsals, we must not be afraid to shorten as far as required. The pictures illustrate some examples of this mana- gement. As a rule now, the metatarsal shortening has to be up to the proximal bases of the first phalanx, on the first ray in severe hallux valgus, on the lesser rays in MTP dislocation or trans- versal inclination of the toes.
IV. EIGHT PRINCIPLES OF FOREFOOT RECONSTRUCTION
360 Forefoot Reconstruction
Fig. 45a1. Principle I – Make a surgery followed by painless postoperative period and early functional recovery. a) The surgery itself.
1. Respect of the soft tissue. Ex.: Keep the soft tissue on the dorsal surface of the metatarsal during Weil osteotomy and fixation.
2. Accurate surgery. Ex.: Double layer in Weil osteotomy both to leave out the protruding spike “a”, to elevate the metatarsal head and to turn the head for better toe ground contact.
3, 4. Accurate and strong fixation of the osteotomies, which allows early functional recovery.
5. Well balanced forefoot, particularly respecting the relative length of the metatarsals.
6, 7. Préoperative bloc injection of a long-lasting anaesthetic (Naropeine).
361 Eight Principles of Forefoot Reconstruction
Fig. 45a2. Principle I – Painless postoperative period and early functional recovery. b) Postoperative precautions.
1. Foot elevated almost non stop during the first two days is the best way not to have postoperative edema. That’s why we prefer “two days surgery” instead of one day surgery (and three days for severe forefoot disorders surgery).
2. Toes strapping (I make the strapping myself, three times during the first postoperative month). It is extremely important during the first three weeks because no strapped toes (particularly the lesser toes) should remain not so well corrected.
3. Self-training three times a day is also essential to complete the correction. The husband should be helpful.
4. The Type I heel support shoe effectively protects the surgery correction of the deformities and allows immediate and painless walking.
5. After one month, tiptoe and toe ground contact training.
362 Forefoot Reconstruction
Fig. 45b1. Principle II – Harmonizing the forefoot around the correction of the most impaired ray.
a) Generalities.
We have to play on several strings/rays.
1, 3. Bilateral problems: If we only consider the right foot, the shortening should be “R”. But we have to focus on the amount of shortening on the most impaired ray which is the first one ray of the left foot: Note that for this first MTP joint, fusion or preservation result in the same resection. This first MTP joint being preoperatively painless and mobile, our choice was preservation. But the amount of shortening was “L” and this was reported on the right foot.
2, 4. Radiological and clinical result (two months postoperative).
363 Eight Principles of Forefoot Reconstruction
Fig. 45b2. Principle II – Harmonizing the forefoot around the correction of the most impaired ray. b) The first ray is the most impaired.
1. Arthritic hallux valgus: Recovering of MTP dorsal flexion thanks to M1 shortening. But since preoperatively M1 = M2, we had to make additional Weil second metatarsal osteotomy.
2. Another case of arthritic hallux valgus: The amount of M1 shortening to obtain correct dorsal flexion leads to shorten the four lesser metatarsals. But there was metatarsalgia which justified this shortening. Radiological results 2.5 years postoperative (bottom, right).
364 Forefoot Reconstruction
Fig. 45b3. Principle II – Harmonizing the forefoot around the correction of the most impaired ray.
c) Lesser rays are the most impaired.
1, 2, 3. In spite of severe hallux valgus, first MTP dorsal flexion is preserved so that the shortening is focused on the second metatarsal.
4, 5, 6. Second ray MTP dislocation.
5. Stable correction is obtained with this shortening. M1 shortening to obtain M1 = M2.
6. One year postoperative radiological aspect.
Fig. 45b4. Principle II – Harmonizing the forefoot around the correction of the most impaired ray.
d) Surgery focused both on the first and second rays.
