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dear all,
53 year old manual worker has has valgus defomity.pictures and x rays are attached.
patient has pain over the medial foot and difficulty in wearing foot wear.
HV angle is 70*, intermetatarsal angle is 30*

my plan is arthrodesis of MTP joint, medial soft tissue release,+/- basal open wedge osteotomy.what about 2nd and 3rd MTP joints..

opine please::confused:

suresh

 

Sureth:
Good luck!
Whatever you do surgically; I would start him on Achilles stretching exercises right away. It looks like he has a MetAdductus and most likely a secondary short achilles. I'm sure you appreciate the added forces applied to the forefoot (particularly post HAV surgery) by a tight Achilles.

Is his pain just over the 1st metahead? If his 2 & 3rd MTPJ are not painful I wouldn't do anything with them. If you feel obligated to correct the IM angle I'm not sure the added length you'll get with an opening wedge is advantageous. You might want to consider a met/cun fusion with correction or a closing wedge.


From what I can see from your x-ray, his IM angle does not appear that large.
Although you may scratch your head at this, I would perform a distal metatarsal osteotomy, making sure the "bump" is gone (moved) and let him know his hallux will still be in valgus after his surgery, but his pain will be gone. Two weeks in a surgical shoe, a nice new orthotic and he can be back at work in 3 or 4 weeks.

Steve

 

thank you drsarbes,
after joining podiatry arena ,am having so much
interest towards foot surgery.

we did, arthrodesis and 1st and 2nd mtp joint,
basal open wedge osteotomy .
3 rd mtp joint found be very difficult to reach
so I did excision arthroplasty.

while trying to corrct the HV defomities there was laerge opening over the 1st web space, thats why we planned to touch 2 nd and 3rd MTP joints.

comments on xrays...

suresh

 

Hi Suresh:
Thanks for the post-op x-ray.
The opening wedge looks very good.
I'd be interested in your technique in fusing the 1st MTPJ.
thanks again
Steve
ps
I hope he doesn't need to get through a metal dedector anytime soon! LOL

 

Interesting pictures!

I am but a humble podiatrist and thus am ignorant of matters surgical. However i do have a few questions re the post op pictures below. Perhaps somebody with a bit more surgical savvy could educate me

The long screw through the 1st mpj, is there meant to be that much screw sticking out of the Phalanx?! Won't it cause ID pain?

Its hard to see where the short screw (Baruk?) in the 1st met is and what its doing, is it through the sesamoid or is it another bit of reinforcement for the 1st mpj

Is the K wire in the 2nd MPJ a fixture or is it coming out? If the latter where is the wire actually sticking out?

What is the benefit of removing the 3rd met head rather than the prox phalanx head? Was the 3rd met causing pressure lesions?

Sorry if these are silly questions!

Regards
Robert

 

Robertisaacs,
many thanks for your questions
i am expecting these for long time... thats why asked comments about the pics

we will remove the screws at 12 weeks period after clinical and radiological signes of union

we found that second screws was not serving the purpose after post operative film.
planning to remove this also at the same time

k wire was in plantar aspect ..
.

on table i planned to do arthrodesis 2nd and 3rd mtp joint.
but i was found to be difficult in reaching 3 rd mtp, hence i did excision
after reading your reply i am now thinking of your suggestion of doing excision f ppx base.

i don't have much experience this procedures...

i am learning more from others, and also finding the way ,how to over come my mistakes.

what is your line of this management for this pt?

suresh





,

 

Nice work on the opening wedge, given your lack of experience. I would put that patient in a cast for 6-8 weeks, non-weightbearing.

Are you planning to do surgery on his other foot?

 

dear Nat,

bk cast was applied pt is on non weight bearing walking.
patient doesn't have any symptom on other foot.

suresh

 

Interesting pictures. Given your lack of experience, may I suggest using intraoperative flouroscopy or x-ray when doing any osseous procedures. This will not only guide your screw placement, but can also provide significant insight into the overall stability of the foot before and after the procedure(s) is completed. I would follow this patient closely and keep him happy - because when he starts to bear weight and/or inspect his x-ray - he may not be.

For sake of argument, and having only the patient information provided, I probably would have treated this as a rheumatoid-type foot - first MTPJ arthrodesis (without base wedge) with lesser metatarsal head resection/hammertoe repair 2-5.

Why did you choose the opening wedge plate? Cool factor? If your heart was set on a proximal bunion procedure, perhaps a closing base wedge or Lapidus would be more appropriate given the need to address the second and third MTPJ. A first MTPJ arthrodesis alone can adequately reduce the IM angle as well.

Just food for thought.
matthew

 

Suresh,
Looking at the bases of the proximal phalanges of the 1st and 2nd toes on your post op x-ray, what have you done? Why do you want to fuse the 2nd MTPJ? When you say you couldn't reach the 3rd MTPJ, why? What incision/s did you use? I haven't come across anyone fusing lesser metatarsophalangeal joints.
"53 year old manual worker has has valgus defomity.pictures and x rays are attached.
patient has pain over the medial foot and difficulty in wearing foot wear" - did you consider less destructive surgery in this young mobile gentleman? (eg. Closing base wedge 1-3? Or the distal osteotomy mentioned above as a first option?) If you had saved the 1st MTPJ, you could have monitored the patient postoperatively to see if he needed the fusion after all. Once you've taken the hardware out, get him some decent orthoses or I suspect you'll see him again (lesser metatarsalgia, etc...). Sometimes less is more.
:confused:

 

bob,
thanks for your comments'

after got the correction of the great toe via medial incision , i felt there was wide first web space( could you suggest any other method to correct this)

then opened through vertical dorsal incision over 2nd and 3rd web space and tried to reduce the 2nd mtp joint, which ended up to the arthrodesis.
foot was immobilsed with BK cast for a period of six weeks.
2nd toe,k wire removal was done.

now he is having short great toe and he is on partial weight bearing walking.


suresh







k wire was removed.

 

Hi Suresh:
Wondering how your patient did?
In a shoe yet?
Symptoms?
Complications?
Is he satisfied?
Wondering what his gait is like with a 1st & 2nd MTPJ fusion.
Steve

 

hi Steve,
i have attached 6 months follow-up of this pt.
pt is now walking with foot wear

but both patient and i struggled a lot during this period.
i have corrected this deformity, but functionally he is not much satisfied

initially:bang:.but now he is adjusted.(no other option) ,:drinks

he had infection over the base of the 2nd toe base during 2nd month post op, treated with debridemet and regular dressing.

but he had taken long time for return to his work.
now he has stiff foot.

suresh[/​

 

Hi Suresh:

Thanks for the follow up and photos.
Sorry to hear about the infection. It happens.

So, 20 20 hind sight (except for the infection) would you do anything differently?
Steve

 

Transosseous capsuloplasty improves the outcomes of Lindgren-Turan distal metatarsal osteotomy in moderate to severe hallux valgus deformity.
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Modified Lindgren-Turan Osteotomy for Hallux Valgus Deformity - a Review of 60 Cases.
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The Modified Subcapital Metatarsal Osteotomy in the Treatment of Hallux Valgus Recurrence.
Scala A et al
Foot Ankle Spec. 2019 Oct

 

Intramedullary locking mini-plate screw system in Lindgren osteotomy: a more effective fixation technique in mild and moderate hallux valgus cases
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