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60 y/o healthy active female with rapidly progressing dislocation of 2nd MTP. Onset of symptoms was mid-summer. July X-rays show beginning stages of doral medial drift of 2nd toe. September films show entire dislocation of toe dorsal/medial/proximal to
2nd MT. Structurally she has HAV (IM 18) and longer 2nd and 3rd MT's. 3rd MT is 12mm longer than 4th and 2nd MT is 6mm longer than 3rd. She has good bone stock. I initially saw her in end of Sept. and started her on conservative care until we could get her surgery scheduled. Any thoughts on surgery selection of 2nd. Plantar plate repair??? Shortening osteotomy of 2nd? 3rd?

Hi Pejka
Given the info you supplied, I would suggest a shortening osteotomy and soft tissue repair of the second. You will have to evaluate whether the 3rd needs to be done. The HAV will need repairing as well.
I have not had a need to repair the "plantar plate" when performing the osteotomy. I use a double inverted "V" method with lactosorb fixation which allows for transverse plane correction as well, but it's the surgeon's choice.
Good luck
Steve

__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Green Bay, Wisconsin, USA

Steve:

Could you describe your double inverted "V" method and what company makes Lactosorb? I've used Orthosorb in the past but its been a while. Thanks for your input.

Carie

Hi Carie:
I've tried many different approaches to shortening a lesser metatarsal and find this method the easiest and most reproducible and fastest healing.
My preop evaluation of how much to shorten (raise) the metatarsal is done clinically. I have found x-ray evaluation very unreliable.
I perform a "v" osteotomy (apex distal) through the surgical neck then feather the distal shaft as needed. If a large amount of shortening is needed I perform a "double" V.

When I feather the shaft I can also adjust the amount taken off the lateral wing of the "V" in order to rotate the head and thus rotate the articular surface. If I know before hand that I will rotate the capital segment then I perform the initial "V" with the apex slightly off center (medial to the midline of the shaft) - this way when the head is rotated you still have quite a bit of bone contact. This may bring up an argument against using a "V" configuration - however the "V" does add innate stability to the osteotomy.

After I feel the osteotomy is correct I take out all retractors, etc...and see how the toe sits. It should be fairly anatomic even without any soft tissue work. If it is not then I take more bone out as needed.

Lactosorb is a fine product, firmer than Orthosorb. It comes in 2.0 and 1.5. I use the 1.5 pin. It's made by Biomet. One percaution with the Lactosorb - once it's in it's in.
Hope I described this well.
Good luck
Steve

__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Green Bay, Wisconsin, USA

Thanks Steve.....