MTP Joint Dislocation of the Lesser Rays

First, we studied the main causes of dislocation, then the principles of surgical correction. The technique of correction is important: We observe that the Weil osteotomy is a great improvement in the correction of the MTP dislocation but on the condition to perform a large proximal sliding of the metatarsal head. The ms point is critical to assess the amount of the metatarsal shortening. The adjacent metatarsals, as well as the whole metatarsal parabola, have to be taken into account. For completing the correction, the Gird-lerstone-Taylor procedure may be helpful, as emphasized by P. Rippstein [103]. This procedure is certainly more effective than the difficult and unpredictable suture of the plantar plate.

Many authors emphasize the reliability and effectiveness of the Weil osteotomy in the correction of MTP dislocation, recently, Hart (66), Jarde (69), Okane (92), Melamed (85), Podsknba (95), Trnka (122), Vandeputte (124).

Mtp Dislocation

Fig. 31a. MTP dislocation - Some causes.

1. Corticoid injection certainly provides MTP dislocation (as emphasized by W. Benton-Weil, Chicago), above all when there is already a predislocation stage with anatomic conditions which promote the dislocation.

2. 3. Excess of lesser metatarsal length.

4. Hallux valgus deformity (above all for the second MTP joint).

Fig. 31a. MTP dislocation - Some causes.

1. Corticoid injection certainly provides MTP dislocation (as emphasized by W. Benton-Weil, Chicago), above all when there is already a predislocation stage with anatomic conditions which promote the dislocation.

2. 3. Excess of lesser metatarsal length.

4. Hallux valgus deformity (above all for the second MTP joint).

2nd Mtp Joint

Fig. 31b1. MTP dislocation - Principles of surgical correction.

1, 2, 3. The best solution is the Weil osteotomy on the condition to have a large shortening (1 or 2 mm more than the phalanx overriding).

4. The head proximal translation is accurately assessed in the medial oblique view, above all when overriding is not large.

5. The corresponding shortening of the first metatarsal has to be assessed on the dorso-plantar view.

6. Toe K-wiring has to be made in most cases. This avoids PIP fusion, preserves as far as possible the first length and the foot elegance (long toes).

7. The resection of the proximal phalanx is not a good solution.

Fig. 31b1. MTP dislocation - Principles of surgical correction.

1, 2, 3. The best solution is the Weil osteotomy on the condition to have a large shortening (1 or 2 mm more than the phalanx overriding).

4. The head proximal translation is accurately assessed in the medial oblique view, above all when overriding is not large.

5. The corresponding shortening of the first metatarsal has to be assessed on the dorso-plantar view.

6. Toe K-wiring has to be made in most cases. This avoids PIP fusion, preserves as far as possible the first length and the foot elegance (long toes).

7. The resection of the proximal phalanx is not a good solution.

Fig. 31b2. MTP dislocation - Technique 1.

1. In this case the proximal translation has to be important, so that it can be assessed on the dorso-plantar X-ray view (ms point).

2. MTP joint approach: Distal section of the long extensor tendon, proximal section of the extensor brevis tendon.

3. 4. Correction of MTP dislocation by soft tissue procedure and at last by the "ciseau de Cauchoix", with its smoothed end.

5, 6. We pointed out the overriding point on the dorsal aspect of the metatarsal, but the real proximal translation of the head is spontaneous, as far as the base of the phalanx is well located without any tension. 7, 8. The first metatarsal shortening is performed to obtain equality of the two first metatarsal lengths.

Fig. 31b2. MTP dislocation - Technique 1.

1. In this case the proximal translation has to be important, so that it can be assessed on the dorso-plantar X-ray view (ms point).

2. MTP joint approach: Distal section of the long extensor tendon, proximal section of the extensor brevis tendon.

3. 4. Correction of MTP dislocation by soft tissue procedure and at last by the "ciseau de Cauchoix", with its smoothed end.

5, 6. We pointed out the overriding point on the dorsal aspect of the metatarsal, but the real proximal translation of the head is spontaneous, as far as the base of the phalanx is well located without any tension. 7, 8. The first metatarsal shortening is performed to obtain equality of the two first metatarsal lengths.

Hallux Valgus Mtp Luxation

Fig. 31b3. MTP dislocation - Technique 2. Reparation of the plantar plate rupture and Girdlerstone-Taylor's procedure.

1. A specimen view showing this rupture (picture communicated by Pr J. P. Delagoutte, Nancy).

2. Dorsal view of the rupture (the flexor tendons are visible in the bottom ) (lft).

3. The suture of the plantar plate is often difficult, and is to make preferably before the metatarsal head fixation.

4. Immediate postoperative view after correction of dislocation and plantar plate suture.

5. 6. Postoperative aspect at the 3rd month.

7, 8. Another solution is the Girdlestone-Taylor procedure (picture provided by P. Rippstein, Zurich) which provides the correction of the remaining dislocation. It is certainly a good solution, but it cannot avoid the Weil osteotomy, and it may be avoided by a large proximal sliding of the metatarsal head.

Fig. 31b3. MTP dislocation - Technique 2. Reparation of the plantar plate rupture and Girdlerstone-Taylor's procedure.

1. A specimen view showing this rupture (picture communicated by Pr J. P. Delagoutte, Nancy).

2. Dorsal view of the rupture (the flexor tendons are visible in the bottom ) (lft).

3. The suture of the plantar plate is often difficult, and is to make preferably before the metatarsal head fixation.

4. Immediate postoperative view after correction of dislocation and plantar plate suture.

5. 6. Postoperative aspect at the 3rd month.

7, 8. Another solution is the Girdlestone-Taylor procedure (picture provided by P. Rippstein, Zurich) which provides the correction of the remaining dislocation. It is certainly a good solution, but it cannot avoid the Weil osteotomy, and it may be avoided by a large proximal sliding of the metatarsal head.

Metatarsal Head Parabola

Fig. 31b4. MTP dislocation - Technique 3.

1, 2. The toe K-wiring allows the toe joints preservation.

3. Suture of the long and brevis extensor tendons with the pulver taff procedure.

The results clearly show that only a sufficient proximal sliding of the metatarsal head (ms point), combined with the respect of the metatarsal parabola, makes reliable the correction of the dislocation; this is shown both in dorso-plantar and in the medial oblique view. The problem of remaining subluxation after surgery is mentioned as well as the problem of MTP subluxation observed in the first time.

Dislocated Toe Surgery

Fig. 31c1. MTP dislocation - Results 1. On dorso-plantar X-rays view.

1. Same foot: Clinical and radiological results (one year follow-up).

2. Same foot that in Fig. 30 b2: Note the correction of both the MTP dislocation and the hammertoe deformity with articular preservation of the MTP and toe joints. Metatarsal shortening: up to the ms point, located on the basis of the proximal phalux

3. Another case before and one year after articular preservative surgery. So the Weil osteotomy with additional K-wiring is an extremely reliable solution for MTP dislocation.

Fig. 31c1. MTP dislocation - Results 1. On dorso-plantar X-rays view.

1. Same foot: Clinical and radiological results (one year follow-up).

2. Same foot that in Fig. 30 b2: Note the correction of both the MTP dislocation and the hammertoe deformity with articular preservation of the MTP and toe joints. Metatarsal shortening: up to the ms point, located on the basis of the proximal phalux

3. Another case before and one year after articular preservative surgery. So the Weil osteotomy with additional K-wiring is an extremely reliable solution for MTP dislocation.

Weil Osteotmy

Fig. 31c2. MTP dislocation - Results 2. On medial oblique view.

Note the required metatarsal shortening, assessed by the ms point.

Metatarsophalangeal Joint Dislocation

Fig. 31c3. MTP dislocation - The correct amount of the metatarsal head proximal translation by the Weil osteotomy.

1. The amount of metatarsal shortening on the dorso-plantar X-ray: As a rule, we have to follow this metatarsal curve.

2. Single Weil osteotomy on the second ray: Insufficient correction of the MTP subluxation results in a too long third metatarsal.

3. The medial oblique view clearly shows that in this case, single Weil osteotomy was performed without enough proximal translation: Stiffness and pain on the MTP joint.

4. In this case, the second metatarsal was really too long both on the dorso-plantar and on the medial oblique views, so that a single second metatarsal Weil osteotomy can respect the metatarsal curve.

5. In this case, Weil osteotomy was necessary in the second and the third metatarsals: It is more frequent.

6. 7. Same foot: Pre and postoperative aspect. Shortening of the four lesser metatarsals: It is the usual surgery we have to do in case of MTP dislocation.

Fig. 31c3. MTP dislocation - The correct amount of the metatarsal head proximal translation by the Weil osteotomy.

1. The amount of metatarsal shortening on the dorso-plantar X-ray: As a rule, we have to follow this metatarsal curve.

2. Single Weil osteotomy on the second ray: Insufficient correction of the MTP subluxation results in a too long third metatarsal.

3. The medial oblique view clearly shows that in this case, single Weil osteotomy was performed without enough proximal translation: Stiffness and pain on the MTP joint.

4. In this case, the second metatarsal was really too long both on the dorso-plantar and on the medial oblique views, so that a single second metatarsal Weil osteotomy can respect the metatarsal curve.

5. In this case, Weil osteotomy was necessary in the second and the third metatarsals: It is more frequent.

6. 7. Same foot: Pre and postoperative aspect. Shortening of the four lesser metatarsals: It is the usual surgery we have to do in case of MTP dislocation.

Plantar Plate Surgery

Fig. 31c4. MTP dislocation - The remaining MTP subluxation after Weil osteotomy.

1. Without suturing the plantar plate, or without the Girdlestone-Taylor procedure, we sometimes observed MTP incongruence (a), which nevertheless usually decreased with longer follow-up (b).

2. A more detailed test shows the correctibility of this incongruence.

3. This incongruence was generally painless and a slight ground contact of the toe is observed.

4-5. When this remaining subluxation is not tolerated, we can make a revision with MTP release and BRT osteotomy on the corresponding metatarsal, sometimes combined with the Girdlestone-Taylor procedure.

Fig. 31c4. MTP dislocation - The remaining MTP subluxation after Weil osteotomy.

1. Without suturing the plantar plate, or without the Girdlestone-Taylor procedure, we sometimes observed MTP incongruence (a), which nevertheless usually decreased with longer follow-up (b).

2. A more detailed test shows the correctibility of this incongruence.

3. This incongruence was generally painless and a slight ground contact of the toe is observed.

4-5. When this remaining subluxation is not tolerated, we can make a revision with MTP release and BRT osteotomy on the corresponding metatarsal, sometimes combined with the Girdlestone-Taylor procedure.

A good way to avoid such remaining subluxation is a large proximal sliding of the metatarsal head. The best way to avoid such remaining subluxation is a large proximal sliding of the metatarsal head.

Ntermetatarsal

Fig. 31d. MTP subluxation - The two recommended procedures.

1. In emerging deformity, the BRT osteotomy may be performed with good results.

2. However, if the corresponding metatarsal is too long, both in dorso-plantar and medial oblique X-ray views, the solution is a single Weil osteotomy.

Both of these procedures have to be combined with MTP dorsal release and to the correction of the hammer or claw toe deformity.

Fig. 31d. MTP subluxation - The two recommended procedures.

1. In emerging deformity, the BRT osteotomy may be performed with good results.

2. However, if the corresponding metatarsal is too long, both in dorso-plantar and medial oblique X-ray views, the solution is a single Weil osteotomy.

Both of these procedures have to be combined with MTP dorsal release and to the correction of the hammer or claw toe deformity.

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