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another in line with the fourth webspace. Dissection was
carried down to the level of the extensor tendons, which
were retracted to allow for access to the MTP joints. All
metatarsal heads were exposed and cut proximal to the
articular surface in a dorsal-distal to plantar-proximal orientation to avoid any plantar bony prominence. Each subsequent metatarsal moving from medial to lateral was made
shorter than the previous in order to maintain an appropriate
metatarsal cascade. Hammertoe corrections were performed
when indicated. MTP joints were then pinned by advancing
a Kirschner wire from the distal tip of each toe into the
metatarsal intramedullary canal. Following lesser metatarsal stabilization, the tourniquet was deflated to ensure adequate toe perfusion. The first MTP joint capsule was then
closed with absorbable suture followed by closure of the
remaining incisions in a layered fashion.
Postoperatively, patients were placed in a well-padded,
short-leg, nonweightbearing splint for 2 weeks. At 2 weeks,
sutures were removed, and patients were then placed in a
short-leg, nonweightbearing cast for another 4 weeks. At
the 6-week visit, radiographs were obtained to ensure
appropriate alignment of the forefoot and to assess for evidence of first MTP arthrodesis healing. Lesser metatarsal
pins were removed at the 6-week visit, and patients were
transitioned to weightbearing as tolerated in a walking boot.
Patients were then allowed to transition into a regular shoe
as their symptoms and swelling allowed.
Statistical Analyses
Student t tests were used to compare preoperative and postoperative clinical and radiographic parameters. Fisher
exact test was used to compare the presence or absence of
lesser toe subluxations or dislocations before and after
forefoot reconstruction surgery. Significance threshold was
set at P <.05.
Results
No patients had any subsequent reoperations either at the
time of final follow-up in clinic or based on phone questionnaire answers. In addition to first MTP arthrodesis and
lesser metatarsal head resections, 14 feet also had other procedures performed during surgery, including extensor tendon (ET) lengthening (n = 2), ET lengthening and PIP
fusions of toes 2-5 (n = 3), PIP fusion of toes 2 to 5 alone (n
=4), triple arthrodesis and gastrocnemius recession with
closed osteoclasis of toes 2 to 5 (n =1), interposition arthrodesis of the first MTP joint and second toe PIP fusion (n=2),
flexor tenotomies (FTs) (n = 2), fourth and fifth PIP fusion
(n = 1), and fourth toe amputation (n = 1). For those patients
requiring bone interposition for first MTP fusion (n = 2), 1
patient previously had a hallux valgus correction complicated by osteomyelitis with subsequent bone loss, and
Foot & Ankle International 38(6)
another patient had a failed prior first MTP joint arthroplasty that led to bone loss of the distal first metatarsal.
Complications were seen in 3 feet, including delayed
wound healing with superficial dehiscence that eventually
resolved with local wound care and oral antibiotics (n = 2),
and wound dehiscence treated with IV antibiotics and subsequent local wound care (n = 1). Wound issues were
observed at the fourth webspace incision (n = 2) as well as
at the second webspace incision (n = 1). Concomitant procedures in these patients included ET lengthening (n = 1),
PIP fusions of toes 2 to 5 (n = 1), and bone interposition for
first MTP fusion (n = 1). All 3 patients eventually healed
their wounds without requiring further surgery.
Patient-Reported Measures
We were able to successfully contact 13 of 14 patients (15
of 16 possible feet). All of these patients provided verbal
consent for the phone questionnaire. For these 13 patients,
mean VAS significantly improved from 6.2 (range: 3-9)
preoperatively to 1.9 (range: 1-6) postoperatively (P <
.001). Notably, 60% of feet (n = 9) reported no pain at the
time of the phone questionnaire.
Mean postoperative satisfaction scores were 9.0 (range:
6-10), with 80% of feet scored at or above 9 (which we
considered as excellent), 2 feet were scored at 7 to 8 (which
we categorized as good), and 1 patient was scored at 6
(which we graded as fair). All patients (13/13) stated they
would undergo the procedure again based on what they
know now about the surgery.
All patients required various foot orthotics preoperatively, but only 3 patients needed foot orthotics postoperatively (2 custom orthotics and 1 OTC). For those patients (n
= 4) needing a cane for ambulatory assistance after surgery,
all stated that this requirement was due to other musculoskeletal conditions (ie, spine, knee, or balance issues). No
patients required long-term narcotic pain medications, and
only 2 patients stated they required occasional anti-inflammatory medications.
Unfortunately, we were unable to compare FAAM scores
before and after forefoot reconstruction. Only 11 patients
completed the FAAM before surgery, and only 2 patients
returned the mailed FAAM questionnaire.
Radiographic Outcomes
Preoperative radiographs were available for review in 15 of
16 feet. One patient's preoperative images could not be
retrieved electronically and, therefore, were not included in
the preoperative assessment. Additionally, 1 patient underwent completion of a previous partial fourth toe amputation
at the time of forefoot reconstruction, with removal of the
residual proximal phalanx. Therefore, MTP alignment was
only able to be assessed for that joint in this patient
Table of Contents for the Digital Edition of Foot & Ankle International - June 2017
Contents
Foot & Ankle International - June 2017 - Intro
Foot & Ankle International - June 2017 - Cover1
Foot & Ankle International - June 2017 - Cover2
Foot & Ankle International - June 2017 - i
Foot & Ankle International - June 2017 - ii
Foot & Ankle International - June 2017 - Contents
Foot & Ankle International - June 2017 - iv
Foot & Ankle International - June 2017 - v
Foot & Ankle International - June 2017 - vi
Foot & Ankle International - June 2017 - vii
Foot & Ankle International - June 2017 - viii
Foot & Ankle International - June 2017 - 1A
Foot & Ankle International - June 2017 - 1B
Foot & Ankle International - June 2017 - ix
Foot & Ankle International - June 2017 - x
Foot & Ankle International - June 2017 - xi
Foot & Ankle International - June 2017 - xii
Foot & Ankle International - June 2017 - 2A
Foot & Ankle International - June 2017 - 2B
Foot & Ankle International - June 2017 - xiii
Foot & Ankle International - June 2017 - xiv
Foot & Ankle International - June 2017 - xv
Foot & Ankle International - June 2017 - xvi
Foot & Ankle International - June 2017 - 3A
Foot & Ankle International - June 2017 - 3B
Foot & Ankle International - June 2017 - xvii
Foot & Ankle International - June 2017 - xviii
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Foot & Ankle International - June 2017 - CT1
Foot & Ankle International - June 2017 - CT2
Foot & Ankle International - June 2017 - 4A
Foot & Ankle International - June 2017 - 4B
Foot & Ankle International - June 2017 - Cover3
Foot & Ankle International - June 2017 - Cover4
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