caspod
Junior Member
Posts: 75
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Post by caspod on Oct 31, 2008 14:51:32 GMT
Probably one for Bill. I am trying to find out up to date information regarding popular (which would obviously be the most successful) techniques used for lesser metatarsal osteotomies. Whether they are performed with just an ankle block and recovery time. Some are listed in Neale's and I have tried a couple of foot and ankle clinic websites (the Birmingham and London ones) online but they do not give any specifics. Have found the Weil's technique, which can also be viewed on facebook uk.youtube.com/watch?v=0e16anygBXYand this paper www.ncbi.nlm.nih.gov/pubmed/8927380Any info gratefully received, thanks. Caroline
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Post by billliggins on Oct 31, 2008 16:44:31 GMT
Hi Cas
There are a multitude of lesser met. osteotomies, all of which are aimed at addressing two basic problems which are usually interrelated: i) long met. ii) plantarflexed met. Both of these anatomical variations cause overweightbearing on the met. head with inevitable P.K. development. The oldest surgery was probably the through and through osteotomy at the neck of the met, allowing the head to find it's own level. This certainly sorted the problem but was often associated with instability and delayed bone healing/pseudoarthrosis. Having said that, I did quite a few of these many years ago with great patient satisfaction, and only by chance saw patients many years later for unassociated problems when Xray picked up pseudoarthrosis. Another technique which I have used is to cut an inverted V behind the met head and allow it to find it's own level. This gives tremendous frontal and transverse plane stability whilst allowing saggital plane mobility. Different surgeons have different views on fixation. My current favourite is the Weil. The met head moves proximally and because of the metatarsal declination angle, dorsally. It offers superb saggital plane stability whilst two screws or wires give good frontal and transverse plane stability. The big advantage, in my view, is that transfer metatarsalgia is much more uncommon with this surgery, rather than the totally unconstrained nature of the aforementioned. Having said that, the former techniques do allow for considerable shortening of the met whilst the Weil does not.
All of these can be carried out under ankle block and all as day case surgery. Bone healing in a healthy individual will take place over 6 weeks; soft tissue swelling will gradually decease over a period of months. Heel weight bearing can take place immediately following surgery and limited but increasing activity after suture removal 12 days post-op.
As with all techniques, no method works every time, all of the time, for every patient!
Hope this is useful. All the best
Bill
P.S. excision of met heads is a no no!
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Post by twirly on Oct 31, 2008 17:02:16 GMT
Hi Bill & Cas, Hi Cas There are a multitude of lesser met. osteotomies, all of which are aimed at addressing two basic problems which are usually interrelated: i) long met. ii) plantarflexed met. Both of these anatomical variations cause overweightbearing on the met. head with inevitable P.K. development. P.S. excision of met heads is a no no! Sticking my neck out (please sharpen the axe before the 1st blow Bill) Would you never consider a pan met resection in certain instances? I bow to your expertise but am intrigued to know if this procedure has any merit in your opinion. Many regards, Mandy
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caspod
Junior Member
Posts: 75
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Post by caspod on Nov 1, 2008 10:49:37 GMT
Thankyou so much for replying so quickly Bill,
This information was primarily for a pt who has bilat forefoot pain, more on the right foot now. She worked in the pub trade for 10 yrs, up to 50 hours a week on her feet and had to give up due to the foot pain. After a consultation with an orthopeadic surgeon earlier this year at the local hospital, he said her right 2nd, 3rd and 4th metatarsal heads were dislocated and left 2 3 +4 met heads were subluxed. She would need an operation to pin them but to try some orthotics first and if they didn't help to go back. She thought that 'pinning the joints' meant that she wouldn't be able to bend her foot again so in a state of flummox forgot to ask the pertinent and important questions like: 'How long will it take to walk properly again' and 'how long will I have to take off work' as she gets no sick pay.
The orthotics supplied by the hospital just have a met raise and had worn down quite a bit by the time she came to me two weeks ago. I stuck a piece of of 3.2mm poron 4000 onto the right met raise as a temporary fix and measured her up for a pair of Robert's Footprints Orthotics, which she has picked up this morning.
Anyway, as she was concerned about having surgery, I had promised her that I would find out some more about techniques used and recovery time etc. She appeared to be alot more positive about it. She even watched Weil's technique on You Tube and wants me to e-mail it to her! Just one more question. Would you operate on both feet at the same time?
Surprisingly, the extra piece of poron I stuck on, although causing pain for the first day, after persevering, she has had no pain since. I also found that when palpating the 2nd mtpj on the right foot, exactly where the worst pain is, it feels like there is a bursa.
Well she left here a happier bunny that two weeks ago and that's what matters. She will keep me updated on her progress.
Thanks again
Caroline
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Post by robertisaacs on Nov 1, 2008 17:37:01 GMT
Very informative post Bill, thanks. Have some Karma.
Robert
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Post by billliggins on Nov 2, 2008 12:54:24 GMT
Tar Robert.
Hi Cas. It sounds as though the orthopod intends to carry out met. osteotomies and an arthrodesis on the affected phalanges. The problem with the latter is that the toe tends to dosiflex because the extensors overpower the flexors due to the dorsal displacement of the met head. I prefer to use an arthroplasty technique and accept that some clawing of the toe will remain. Surgery is always the final treatment and if she is happy with orthoses, I would encourage her to continue down that route. It is frequently the case that a bursa underlies the met head in such cases - I would go so far as to say that painful bursitis is frequently the reason that the patient seeks treatment. However, given this patient's history, I'm willing to bet that her plantar plates have been distally displaced in which case it sounds as though Robert's devices should do the job very nicely (you owe me a pint Robert). It is always possible to operate on both feet. The positive is that there is only one surgical episode and one recovery period. The negatives are that the surgery would have to be carried out under G.A., the patient would have to be hospitalised up to a week post op.; consequently there would be an increased chance of DVT and hospital aquired infection, and that post-op. mobility would be reduced.
Hi Twirly. Yes, pan metatarsal head resection (Hoffman and Clayton procedures) has a place. However, these techniques are described as 'heroic' and are reserved for very severe deformity such as that found in a RD patient. Very definitely not to be undertaken lightly!
All the best
Bill
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Post by robertisaacs on Nov 5, 2008 18:11:18 GMT
;D Now where have i heard that before...
Such is the matured wisdom of Sir Humphrey Appleby. A wise man indeed!
Regards Robert
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