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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..
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
__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Green Bay, Wisconsin, USA
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.
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
__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Green Bay, Wisconsin, USA
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?
Robertisaacs,
many thanks for your questions
i am expecting these for long time... thats why asked comments about the pics
Quote:
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?
we will remove the screws at 12 weeks period after clinical and radiological signes of union
Quote:
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
we found that second screws was not serving the purpose after post operative film.
planning to remove this also at the same time
Quote:
s the K wire in the 2nd MPJ a fixture or is it coming out? If the latter where is the wire actually sticking out?
k wire was in plantar aspect ..
.
Quote:
What is the benefit of removing the 3rd met head rather than the prox phalanx head? Was the 3rd met causing pressure lesions?
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.
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.
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.
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.
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.
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
__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Green Bay, Wisconsin, USA
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.but now he is adjusted.(no other option) ,
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.
Transosseous capsuloplasty improves the outcomes of Lindgren-Turan distal metatarsal osteotomy in moderate to severe hallux valgus deformity.
Ozkan NK, Güven M, Akman B, Cakar M, Konal A, Turhan Y. Arch Orthop Trauma Surg. 2009 Oct 15. [Epub ahead of print]
Quote:
INTRODUCTION: Lindgren-Turan osteotomy used in hallux valgus deformity is a subcapital, transverse displacement osteotomy of the first metatarsal without any additional capsular repair. The aims of this study are to describe a transosseous capsuloplasty technique in this procedure and evaluate whether capsuloplasty would improve the clinical and radiological outcomes in patients with moderate to severe hallux valgus deformity.
METHODS: Twenty-three feet operated by Lindgren-Turan osteotomy (Group B) and 25 feet operated by the same osteotomy combined with transosseous capsuloplasty (Group A) were evaluated retrospectively for the correction of the hallux valgus, intermetatarsal and distal metatarsal articular angles, sesamoid reduction, American Orthopaedic Foot and Ankle Society (AOFAS) Clinical Rating Scale as well as patient satisfaction. The mean postoperative follow-up was 14 (range 12-28) months.
RESULTS: All radiological parameters improved considerably as a result of both groups. However, postoperative improvements in intermetatarsal and distal metatarsal articular angles were greater in Group A. Complete reduction of medial sesamoid was achieved in 52% of patients in Group A, whereas 17.4% of patients in Group B had complete reduction. AOFAS scores and number of patients with complete satisfaction in Group A were significantly greater than that in Group B.
CONCLUSION: Better clinical and radiological outcomes can be achieved in patients with moderate to severe hallux valgus deformity operated by Lindgren-Turan distal metatarsal osteotomy, when it combines with transosseous capsuloplasty.
Surgery for severe hallux valgus
.but now he is adjusted.(no other option) ,
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