2024 Metatarsalgia.pptx

Metatarsalgia M AT H E W J O H N S T O N E D P M , FA C FA S , D A B P M A S S I S TA N T P R O F E S S O R C P M S DES MOINES UNIVERSITY Copyright notice This presentation may contain copyrighted material used for educational purposes under the guidelines of Fair Use and the TEACH Act. It is intend...

Metatarsalgia M AT H E W J O H N S T O N E D P M , FA C FA S , D A B P M A S S I S TA N T P R O F E S S O R C P M S DES MOINES UNIVERSITY Copyright notice This presentation may contain copyrighted material used for educational purposes under the guidelines of Fair Use and the TEACH Act. It is intended only for use by students enrolled in this course. Reproduction or distribution is prohibited. Unauthorized use is a violation of the DMU Integrity Code and may also violate federal copyright protection laws. Learning Objectives 1 Identify the differential diagnoses for metatarsalgia based on the history, physical exam and/or imaging studies. 2 Identify conservative management of metatarsalgia. 3 Identify surgical management options for metatarsalgia “Metatarsal gia” Meta- Latin “Next after, between” Tarsus- Latin “of or pertaining to the ankle or instep” Algia- Latin “Pain” from Greek álgos, “pain” Biomechanics Lecture overview First ray insufficiency Angular deformities “Metatarsal parabola” Equinus Sesamoiditis Turf-Toe Fractures and stress fractures Morton’s Neuroma Intermetatarsal Bursitis Callusing Abnormal levels of pressure and shear force combine to lead to increase thickness of the stratum corneum, stratum granulosum, and keratinocytes. This leads to a positive feedback as the callus itself increases the pressure on the local area, leading to more callusing, pain and even breakdown of the skin. Corn: A hyperkeratosis with a central keratinized plug, underlying dermis often shows signs of mechanical damage such as fibroblast proliferation Callus: a wide hyperkeratosis without central keratinized plug, often encountered under the metatarsal heads. Biomechanical sources of Callusing and pain: First ray hypermobility The first ray has an independent axis of motion, while the second and third rays are far more limited Increased dorsiflexion of the first ray (hypermobility) leads to increased pressure borne by the second and third metatarsals. This increase in pressure can lead to pain, callusing, even joint degenerations Hypermobility of the first ray alone is not necessarily a guarantee of metatarsalgia First ray hypermobility clinical exam Review from biomechanics course: ◦ Stabilize the 2nd-5th ray with one hand ◦ Grasp the head of the first metatarsal with the other ◦ Travel of over 5mm is “hypermobile” First ray hypermobility: Radiographic appearance Plain film Xray findings of hypermobile (and unstable) first ray include: ◦ Increased talar-first metatarsal angle ◦ Top image ◦ Plantar “gapping” of the first metatarsalcuneiform joint. ◦ Middle image: white arrow showing gap ◦ Bottom image: very large gap of late-stage instability Sagittal plane Angular deformities of the metatarsals First metatarsal Elevatus ◦ Can be seen as a posttraumatic, Iatrogenic, or congenital etiology of increased forefoot pressures ◦ Radiographic appearance is that of a true widening angle distally of the dorsal first metatarsal cortex compared to the second metatarsal cortex on the lateral view. ◦ Shown on image below Sagittal plane angular deformities of the metatarsals: Lesser metatarsals Structural plantarflexion of the central metatarsals leads to increased pressure on the affected metatarsal head Structurally dorsiflexed central metatarsals result in increased pressures on the adjacent metatarsal heads Sesamoid axial view can be used in evaluation of preop (and postoperative) position Transverse and frontal plane deformities of the metatarsals While they are less predicable and less obvious than the sagittal plane deformities it is easy to imagine how a deformity like hallux abductovalgus and these mal-positioned lesser metatarsal fractures could change the normal distribution of weight to the forefoot. The metatarsal parabola: lengthdependent deformities Barring any angular anomalies, the metatarsals share the load placed upon the forefoot together ◦ This is based on ideal position relative to one another ◦ Alterations in the structure of the parabola, especially as this relates to the first and second metatarsals leads to alterations in the gait and forefoot pain Metatarsal protrusion Radiographic evaluation ◦ Create parallel lines at the distal extend of each metatarsal head ◦ Measure the distance between the lines ◦ Normal is 2-4mm Increased protrusion distance is not necessarily indicative of future pain in asymptomatic individuals. ◦ However, prior studies have correlated increased metatarsal protrusion with metatarsalgia/ plantar plate injuries. Structural deformity: Enlarged lateral condyle Occasionally, the fibular condyle of the plantar metatarsal head will become hypertrophic in response to trauma, or may be congenitally enlarged Equinus Structural (bony) equinus and dynamic ◦ Increased plantar metatarsal head pressure by limiting area of contact ◦ Increased plantar metatarsal head pressure by causing early heel-off Conservative treatment of biomechanical metatarsalgia Address the pertinent deformity ◦ Orthotics/offloading ◦ Metatarsal cutout ◦ Metatarsal bar/pad ◦ Morton’s extension/reverse Morton’s ◦ Stretching ◦ Achilles stretching at home (consistency is key) ◦ Physical therapy ◦ Callus/skin care ◦ Debridement ◦ Skin care routine/moisturizers (next slide) Callus/ Skin care Emollient: Oily occlusive layer to prevent water loss from the skin Representative Representative chemicals: chemicals: lanolin, lanolin, petroleum petroleum jelly, jelly, mineral oil Humectant: Increases skin skin moisture level by drawing and and retaining water retaining water molecules molecules to to the the skin skin surface surface Representative Representative chemicals: Propylene Glycol, Glycol, glycerin, glycerin, lecithin Keratolytic: Keratolytic: Unfolds Unfolds and and destroys the keratin destroys the keratin of of the the stratum stratum corneum, corneum, eventually eventually leading leading to to softening softening or or even even sloughing sloughing of of callus. callus. Urea, Urea, glycolic glycolic acid, salicylic salicylic acid Surgical treatment of lesser metatarsal deformity Considerations: ◦ Which deformity are you trying to address? ◦ Long metatarsal? ◦ Angulated metatarsal? ◦ Metatarsal malunion or deformity? ◦ First ray insufficiency? ◦ Equinus? ◦ How will this affect the other metatarsals once it is done? ◦ Patient candidacy for surgery ◦ Patient education regarding expectations for surgery Metatarsal shortening osteotomy Also known as the “Weil osteotomy” Oblique cut from distal dorsal to plantar proximal Bone-cut begins at the dorsal articular cartilage (A) Oriented parallel to the weight wearing surface Slide the metatarsal head proximally (B) Resect the residual dorsal metatarsal (C) Fixate with 2 small screws (1.5mm or 2.0mm) (D) Dorsal distal closing wedge osteotomy Original was designed at 90 degrees to the shaft of the metatarsal, modified for screw fixation Dorsal wedge of bone removed ◦ Elevates the metatarsal head slightly ◦ Rotates the plantar cartilage dorsally ◦ This may be very useful for early stage Frieberg’s-type lesion Helal osteotomy Designed in 1975 as a dorsal proximal to plantar distal cut Care is taken to avoid the plantar condyles in order to avoid disrupting the plantar plate Head of the metatarsal is supposed to be translocated (slid) dorsally, not dorsiflexed Historically has not produced great results with multiple studies reporting less than satisfactory outcomes. Distal metatarsal “V” osteotomy Allows For shortening and elevating the head of the metatarsal ◦ Can remove a small secondary “V” to shorten Technically more difficult to perform Fixation is more difficult to orientate ◦ Often left unfixed to “find its own level” Proximal metatarsal closingwedge chevron osteotomy Originally developed as a salvage procedure for diabetic ulcerations Chevron-arms oriented at 60 degrees to each other, a second chevron would be cut to converge at the plantar cortex Metatarsal would be manually elevated until it was no longer prominent at the forefoot Fixated with crossed 3.5mm screws or K wires The “BRT” osteotomy 2018: Drs Barouk, Ripstein and Toullec introduced a proximal oblique closing wedge of the lesser metatarsal base for correction of cavo-varus forefoot deformity Distal dorsal to proximal plantar cut beginning 1cm to 1.5cm from the proximal metatarsal edge Cut is orientated at 60 degrees rom the perpendicular axis of the metatarsal (see top right image) Proximal hinge left intact Fixated with a screw at 90 degrees to the osteotomy, or staple dorsally Plantar Condylectomy Reserved for cases of truly hypertrophic plantar condyles This type of resection is far easier if paired with another metatarsal osteotomy which elevates the head of the metatarsal. Theoretically does not alter the biomechanics of gait Increased chance of recurrence Decreased chance for transfer lesion Postoperative care Postop ◦ Distal procedures ◦ WB in postop shoe for 6 weeks if fixated ◦ If not fixated may consider NWB ◦ Proximal procedures ◦ NWB for 6-8 weeks Complications ◦ May lead to “floating toe” ◦ Transfer lesions ◦ Risks of Delayed unions or nonunion without fixation Sesamoiditis S E S A M OI D - E N GL I S H - “OF OR L I K E A S E S AM E S E E D” (FR OM A RA B I C - S E M S E M “ S E S A M E S E E D” ) - IT I S - L ATI N – “ I N FL A M M ATI O N ” Hallux Sesamoiditis clinical presentation Patient will usually not recall any single traumatic event prior to onset Diffuse pain, localized to the plantar forefoot; worse with walking Pain increased with forced dorsiflexion of the great toe ◦ May even present with a positive “dorsal drawer sign” Pain during gait, especially toe off. Patient may overload the lateral foot visibly to “walk away” from the plantar first MTPJ Localized edema to the plantar first MTPJ Palpation of the tibial sesamoid may elicit positive tinels sign due to compression of plantar medial nerve Hallux Sesamoiditis: Xrays May show degenerations or acute fractures well Must be distinguished from normal anatomical variants (bipartite Sesamoids) Useful Views: ◦ Medial oblique: tibial sesamoid ◦ Lateral oblique: lateral sesamoid ◦ Sesamoid Axial Bipartite sesamoids Anywhere between 7 to 30 percent of the population has a bipartite sesamoid (bi-Latin-”two”, Partire-Latin –”to part”) Most (over 90%) are the tibial sesamoid 80-90% will also have a bipartite on the other foot Bipartite sesamoids may be distinguished from fractures of the sesmoid by the “rounded” edges vs jagged fracture lines ◦ May need a CT to distinguish the lines Bone scan may be useful to differentiate fracture and bipartite ◦ Up to 25% of asymptomatic people will have a positive sesamoid bone scan MRI is more accurate for demonstrating sesamoid fracture, as well as AVN of the sesamoids ◦ Expensive! Sesamoiditis/acute sesamoid fracture conservative treatment Fortunately, most cases of sesamoiditis respond to nonoperative care ◦ Fractured sesamoid less likely to respond Reverse Morton’s extension or dancer's pad Immobilization Stiff soled, rocker bottom shoes with soft cushioned inserts ◦ Make sure these have a low heel Turf toe taping/strapping of the great toe Activity modifications ◦ Gradual return to activity when improved Sesamoid Fracture: Usually associated with trauma ◦ Including repetitive microtrauma Check BILATERAL x-rays ◦ About 9/10 patients with a naturally bipartite sesamoid have the same finding on the contralateral foot (see bottom image) ◦ Top image: fracture of the right tibial sesamoid ◦ Bottom image: bipartite tibial sesamoids. Sesamoid fracture: MRI MRI findings typically mirror other fractures T1: hypo intensity T2: hyperintensity Sesamoid fracture: ORIF Dissection will be shown in greater detail in a few slides (turf toe section) Single screw fixation can be used to repair a linear sesamoid fracture ◦ Use headless, self-drilling, self tapping, screw usually a 2.5mm Sesamoidecto my Indicated for recalcitrant cases or infected sesamoid bones Medial dissection shown for tibial sesamoidectomy, fibular can sometimes be excised dorsally through a hallux-lateral-release-style incision Can result in deviation of the away from the resected sesamoid ◦ Remove tibial Hallux valgus ◦ Remove fibular Hallux varus Turf toe Turf toe: Clinical Presentation Patient generally reports the hyper-extension trauma Skin may display ecchymosis and localized edema Inability to reach maximal hallux dorsiflexion without severe pain Positive dorsal drawer test (think Lachman’s, but for the great toes) ◦ Compare this to contralateral side. Turf toe: X-ray appearance The AP view may show a proximal migration of the hallux sesamoids ◦ Compare this to the contralateral side Be sure to check the oblique views to evaluate for concomitant sesamoid fractures Turf toe: MRI MRI is useful for cases with recalcitrant clinical symptoms or vague presentations T2 sagittal plane view is pictured top right with the large red arrow indicating a mid-substance rupture of the plantar plate T1 view of the normal plantar plate is pictured bottom right, the small red arrows indicate the normal flexor tendon. ◦ A more obvious rupture (arrows) (T1 left T2 right) is seen below with retraction of the sesamoids Turf toe: conservative care Taping/strapping ◦ Stabilize the hallux, prevent dorsiflexion Immobilization ◦ CAM boot ◦ Stiff soled shoe ICE Rest/activity modification Oral NSAIDs *most cases will respond to conservative care* Turf toe: surgical treatment Reserved for progressive, or persistent symptoms Goals: ◦ Restore the position of the sesamoids ◦ Repair the plantar plate tear ◦ Do not over-tighten ◦ Avoid the neurovascular anatomy (nerves pictured) Let's do: A turf toe repair Plan your incision ◦ A medial “L” type incision is preferred is both medial and lateral aspects of the plantar plate are injured ◦ Isolated medial approach (pictured below) may be sufficient for medial- only tears. ◦ Be conscious of the neurovascular anatomy in this region. ◦ Dissect in layers…CAREFULLY Turf toe repair: dissection Carry the dissection down to the level of and identify the digital neurovascular bundles Be very gentle with skin and deep tissue retraction ◦ Use silicone vessel-loops to retract the N/v bundle Turf toe repair: deep dissection Usually, the tear is distal Begin the deep dissection of the capsule from distal to proximal *note the vessel loops retracting the n/v bundle on the plantar side of the incision* Turf toe repair: check Ensure that the plantar plate is able to reach the distal attachment with the toe positioned in neutral ◦ You may have to augment the repair with tendon Turf toe repair: the repair This is a strong non-absorbable suture called fiber wire ◦ For central tears: repair the tear end to end (top) ◦ For distal tears: use bone tunnels or anchors to reattach the torn plate to the hallux proximal phalanx. (bottom) Inspect the joint while you are making the repair, remove any loose bodies, drill any OCD on the first met head Do not overtighten the joint ◦ Hallux flexion deformity Turf toe repair: closure Check the tension of your capsular repair with passive ROM ◦ Again: do not overtighten Turf toe: final check M A K E S U R E T H AT T H E SESAMOIDS ARE WELL P O S I T I O N E D BY TA K I N G C O M PA R I S O N V I E W S Turf toe repair: Postoperative care Bulky padded dressing Check in office in 7-10 days for infection Taping or splinting must be continued at least 4 weeks after surgery Weight bearing at about 4 weeks (if sutures removed without issues) Start passive range of motion exercises ◦ Keep this under 10 degrees of dorsiflexion at first ◦ Perform the passive Rom with the ankle in plantarflexion and knee flexed ◦ Mitigate the pull of the gastrocnemius and plantar fascia on the repair Controversy in return to impact activity ◦ 12 weeks? Stress fractures A true overuse injury 95% involve the lower limb Some sports seem to be more prone to stress fractures, namely track and field Common in military recruits (periods of increased activity) Aristotle said this of successful athletes: “Those who do not squander their powers by early and overtraining.“ Stress fractures: clinical appearance Similar presentation to Predislocation syndrome is common Runner/ high activity patient Period of increased activity or exercise (training) Pain and swelling (sometimes Bruising) localized to the forefoot Clinical exam positive for POP, and may be positive for tuning fork test placed over the metatarsal head. STRESS FRACTURE: XRAY APPEARANCE RIGHT IMAGES ARE 4 WEEKS LATER Stress Fracture CT appearance CT may demonstrate a more subtle periosteal reaction (top) or hairline fracture (bottom) CT is also very useful for making out hairline fractures at the metatarsal bases that are difficult to visualize on plain film. STRESS FRACTURE SCINTIGRAP HY FINDINGS Bone scans will generally be positive on the blood pool (30 minutes) and delayed phases due to increased bone turnover. Very sensitive scan, not very specific Difficulty with specifics of location MRI Findings MRI of stress fracture will typically show hyperintensity on the T2 weighted imaging and Hypointense on T1. MRI should be examined for other similar-presenting pathology such as plantar plate ruptures Treatment Fortunately, surgical treatment of stress fractures is rarely indicated Immobilization is the mainstay- allow for healing by ceasing harmful motion ◦ Cast ◦ CAM boot ◦ Make sure to inform patient of the height-differential (bottom image) ◦ Postop shoe ◦ Rocker shoe ◦ Activity modification NSAIDS ICE Even in true metatarsal fractures surgery rarely indicated ◦ Unless… Stress fractures: rest period? The above guidelines were proposed in 1997 by Arendt EA, Griffiths HJ et al. in clinics of sports medicine Metatarsal fracture (distal) While Metatarsal base fractures are treated as midfoot injuries (fifth met base, lisfrancs) distal fractures are less commonly operated upon Surgical indications rest upon degree of ◦ Displacement >4mm ◦ Angulation >10 degrees ◦ Instability: ◦ Comminution ◦ Multiple fractures Metatarsal fracture repair Approach: ◦ Dorsal: for more complex fractures of those of the shaft/base ◦ ORIF ◦ Percutaneous: may be appropriate for head/neck fractures or poor surgical candidate ◦ Pinning (pictured) Let do: a metatarsal base fracture ORIF Radiographically: note any angulations or displacement, these will need to be corrected. Consider neurovascular anatomy when designing your incisional approach Metatarsal ORIF: incision Try to place this as close to the fracture as possible without violating the n/v anatomy. ◦ Minimize dissection=less postop morbidity Metatarsal ORIF: dissection Identify and retract tendons as you approach the periosteum and bone Metatarsal ORIF: periosteal incision To visualize the fracture line you must incise the periosteum ◦ This is also needed to evacuate any hematoma formed in the fracture line ◦ You also want any plating directly on the bone, not compressing periosteum Metatarsal ORIF: temporary stabilization Stabilize the fracture with a clamp or wire, and line-up your plate. Check the position with intraoperative fluoroscopy Metatarsal ORIF: fixation Simple fractures like this representative second metatarsal fracture may be fixated with a lag screw, and plate. More complex comminutions such as the third met fracture illustrated here require bridge plating, temporary stabilization with crossed Kwires shown Metatarsal ORIF Make sure that the plate and heads of the screws will not be prominent against the skin, you will have to close the deep tissues over this somehow. Metatarsal ORIF: radiography Make sure that you are satisfied with the position of the repair in the OR before closure Ensure that there is no sagittal plane elevation, or transverse plane angulation which will predispose the patient to transfer lesions Morton’s neuroma Named for Thomas George Morton (1835-1903) ◦ American general surgeon based in Philadelphia ◦ Gained renown for treatment of soldiers wounded in the US Civil war ◦ Performed the first appendectomy ◦ Founded several humane societies ◦ Prevention of cruelty to children ◦ US anti-vivisection society Also known as perineural fibrosis or perineural fibroma ◦ Misnomer: This is not a true neoplasm ◦ Most common in middle aged patients ◦ Far more common in women than men Morton’s Neuroma: clinical features Sharp pain in the forefoot while walking ◦ Pain may radiate from mid-metatarsal level to the toes Worse in shoes Usually, no swelling seen May accompany paresthesia ◦ Feeling of a “rolled up sock” or pea/stone in the shoes Morton's neuroma: Clinical exam M E TATA R S A L S Q U E E Z E T E S T (TOP) MULDER’S SIGN (BOTTOM LEFT) D I G I TA L S E N S AT I O N ( B O T T O M RIGHT) Morton’s neuroma: Xrays Useful for evaluation of other similar-presenting conditions Not sensitive for neuroma as this is a soft tissue pathology ◦ May show the “Sullivan’s sign” ◦ A divergence of the toes ◦ This has been shown to be specific for neuroma, not sensitive ◦ Also sometimes known as the “Vulcansalute sign” Morton’s neuroma: Ultrasound Located in the intermetatarsal space proximal to the metatarsal head round to ovoid Well-defined Hypoechoic Non-Compressible Superficial to the DTIML on the plantar aspect Morton’s Neuroma: MRI Ovoid or barbel shaped appearance located in the intermetatarsal space proximal to met heads Most commonly the 3rd pedal interspace T1: Hypo- or iso intense T2: Hypointense, sometimes can be intermediate in signal Contrast: variable enhancement Morton’s Neuroma: Conservative treatment Offloading: metatarsal pads Wider, flat shoes Injections: ◦ Ultrasound guided or blind steroid injection into the interspace ◦ Goal: Atrophy the fibrotic tissue around the nerve ◦ 4% sclerosing alcohol injection ◦ A: Solution: prepare in office ◦ 48ml of 0.5% bupivacaine HCl with EPI (1:200,000) ◦ 2mL of dehydrated alcohol for injection Inject just proximal to the “bulb” ◦ Repeat every 5-10 days ◦ Up to 7-9 injections ◦ Dockery had 89% success rate ◦ Goal: ablate the fibrotic tissue and nerve ◦ B: Neuroma: surgical management Last resort Counsel patient: this removes the intermetatarsal nerve as well There will be postoperative numbness (at best) Several surgical approaches ◦ Plantar: easiest approach ◦ Dorsal: Most common approach Neuroma: alternative surgical management Cryogenic denervation: ◦ Minimally invasive ◦ Temperature required to elicit Wallerian degeneration of axons and myelin leaving perineurium and epineurium intact ◦ -50°C to -70°C Results not permanent Can’t use on large neuromas May prevent stump neuroma Let’s do: an intermetatar sal neurectomy Dorsal approach avoids any NWB period required of the plantar approach as well as some of the less savory complications. Plan your incision overlying the affected interspace Neurectom y: incision A 3cm long dorsally placed incision should be enough exposure Neurectom y: dissection Use blunt dissection (stick and spread) to go through the fat layers and spare any dorsal cutaneous nerves Neurectomy: dissection Top image: that looks like a big crossing vein (it is) Middle image: bluntly dissect around the vein Bottom image: you can see not there are two branches ◦ Only one of these (the distal one) is in the way ◦ You can often retract a larger portion of the crossing vein out of the way safely after cauterizing then transecting a smaller segment (in this case the distal part of the “Y” in that vein) Neurectom y: Exposure Place the lamina-spreader between the metatarsal heads ◦ Be careful not to place too much tension on the spreader, you don’t want to fracture the metatarsals. Neurectomy: the DTIML Identify the Deep transverse intermetatarsal ligament (arrow top) and section it (bottom) Neurectomy: The neuroma Plantar pressure on the interspace should reveal the mass. The nerve courses PLANTAR to the DTIML Alternatively, many surgeons prefer to “decompress” the interspace rather than resect the nerve, this involves bluntly dissecting the nerve course. Neurectomy: postop care Postoperative shoe with protected weight bearing x2 weeks Sutures out in clinic at 2 weeks. Increase activity as tolerated Be sure to inform patients of postop expectations (numbness) Neurectomy: complications S M A L L P E RC E N TAGE O F PATI E N T S W I LL DE V E LO P A S TU M P N E UR OM A A R E C UR R E N T PA I N FU L FI B R O S I S AT T H E C UTE D G E OF T H E N E RV E Intermetatar sal bursitis Mimics the symptoms and clinical appearance of intermetatarsal neuroma almost exactly Can be radiographically distinguished by ultrasound in that it IS compressible And MRI coronal view extruding out plantar to the metatarsal heads Lecture Review Visualize how biomechanical abnormalities such as elongated, plantarflexed, dorsiflexed or shortened lesser metatarsal can affect the function of the forefoot Recognize radiographic features of structural abnormality in the forefoot Understand the relationship between equinus and forefoot pain Recognize the clinical presentation for each of the discussed pathologies Apply clinical judgement when selecting appropriate clinical and diagnostic exams for each. Give reasonable conservative options for each pathology ◦ Injection? Immobilization? Strapping/bracing? Recognize the anatomical locations of pain, associated with each, this is especially important when considering surgical incisional approach ◦ Why would you do it like this? What anatomy is at risk? Identify strengths and drawbacks of the surgeries discussed here. ◦ Where would you favor one over the other? What is the surgery designed to do? If there is more than one approach described, why? How do I study for THIS?: sample question 1 1. Which of the following procedures would be able to provide the MAXIMUM angular correction a severely plantarflexed second metatarsal in a 67-year-old female patient with newly diagnosed CMT, peripheral neuropathy, and a pre ulcerative callus underneath the second metatarsal head? a. Plantar condylectomy (resect the plantar Met head) b. Helal osteotomy (distal dorsal translocation) c. BRT osteotomy (proximal closing wedge) d. Distal Chevron osteotomy e. Weil osteotomy (shortening oblique) 1. What would be the advantage of performing a PLANTAR incision for an intermetatarsal neurectomy Sample question 2 a. Do not need the Weil osteotomy b. Reduced period of non-weight bearing c. Preserve the Deep transverse intermetatarsal ligament d. Ease of approach e. Both C and D Sample question 3 1. The incision shown here was most likely made in preparation to address which pathology? a. b. c. d. e. Metatarsal fracture Freiberg’s infarction Predislocation syndrome Extensor substitution Morton’s Neuroma 1. Which of the following procedures would be able to provide the MAXIMUM angular correction a severely plantarflexed second metatarsal in a 67-year-old female patient with newly diagnosed CMT, peripheral neuropathy, and a pre ulcerative callus underneath the second metatarsal head? Rationale question 1 a. Plantar condylectomy (resect the plantar Met head) b. Helal osteotomy (distal dorsal translocation) c. BRT osteotomy (proximal closing wedge) (correct answer!) d. Distal Chevron osteotomy e. Weil osteotomy (shortening oblique) (Rationale: Proximal osteotomies allow for high degrees of correction. This makes choice C ideal, additionally when performed as described, choices A B,D and E are not angular corrections. The medical history provided in the question header is a red herring) 1. What would be the advantage of performing a PLANTAR incision for an intermetatarsal neurectomy Rationale for question 2 a. Do not need the Weil osteotomy b. Reduced period of non-weight bearing c. Preserve the Deep transverse intermetatarsal ligament d. Ease of approach e. Both C and D (correct answer!) (Rationale: the intermetatarsal nerve courses plantar to the DTIFL, which is why this ligament must be transected as part of the dorsal approach, choices C and D are correct, plantar approach does require prolonged non weight bearing compared to the dorsal and neither require a Weil osteotomy. (this is a neurectomy not a plantar plate repair!) 1. The incision shown above was most likely made in preparation to address which pathology? Rationale: sample question 3 a. Metatarsal fracture (correct answer!) b. Freiberg’s infarction c. Predislocation syndrome d. Extensor substitution e. Morton’s Neuroma Rationale: This is an extrapolation question, using your knowledge of these conditions and the recommended surgical approach, one should be able to identify the proper anatomical location of this incision placement. It is too far proximal to be any of the incorrect answers (perhaps a case could be made for a hibbs tenosuspension (extensor substitution hammertoe answer) however this incision is too small for that procedure and does not extend to the MTPJ)