05/09/2013    Don Peacock, DPM

Chronic First MPJ Pain (Charles Morelli, DPM)

I have to respectfully disagree with Dr. Morelli
regarding this particular case. I too am fan of
the of Cotton procedure and it is a great way to
stabilize the medial column and achieve
plantarflexion of the first ray.

Addressing of the gastrocnemius equinus will give
you plantar flexion of the first ray as well.
When I first heard of this I was very skeptical
myself. The reason plantarflexion of the first
ray occurs after a gastrocnemius recession is
because improved mechanical advantage is seen in
the peroneal longus following the recession.

This finding was presented at the North Carolina
Winter scientific seminar by Dr. Barry Johnson
DPM and Deep Patel, DPM. This was extremely
interesting and has changed some of my attitude
towards automatically stabilizing the medial
column with procedures such as a Cotton.

The met declination angle preoperatively is
approx 19. The postop metatarsal declination
angle is approx 24. If you look at the tailor
tilt angle as it compared to the first
metatarsal, you can see that pre-operatively
these two lines would bisect suggesting that the
first ray is elevated relative to the talar
tilt. However, postoperatively these two lines
are parallel suggesting that a more normal
medial column has been achieved and
plantarflexion of the first ray.

The height of the navicular pre-operatively as
opposed to post-operatively displays a pre-op
height of 4.4 cm and post-operatively is 4.9 cm.

The literature states that a potential
complication from a Cotton is increased mid foot
faulting and is the opposite of what you would
hope for. The EGR has less complication and
recovery.

I do believe that correcting her condition with a
Cotton would give a good result. However, in
this case, it may not be quite is optimal because
she has a normal first metatarsal protrusion and
ironically, her metatarsal declination angle pre-
operatively is in the normal range. So
plantarflexing the medial column via bone graft
may not be the best option for her.

Remember this patient is completely pain-free
following this procedure. So our goal of treating
the patient has been achieved. I also will not
argue the validity of minimal incision surgery as
opposed to traditional surgery. They are simply
two separate disciplines each having some inherit
advantages and obvious disadvantages.

Complications do not discriminate on the size of
the incision.

I appreciate the compliment that Dr. Gordon gave
me on my surgical results. Getting a compliment
is always a good thing and I appreciate that.
Fixating with a 6.2 K wire is certainly an
option. Lately, I am beginning to believe that
first ray distal metatarsal osteotomies may
actually heal better without fixation. This is
certainly case with my MIS procedures. In
Austin’s original research he described 1,200
cases which all were performed without fixation.
His findings and conclusions resulted in no
nonunion’s and no AVN. He also stated that
fixation was not necessary.

Healthy debate can be had when trying to
determine the most appropriate procedure to
perform with any type of hallux limitus case.
There is disagreement even in the literature
Some prefer decompression and some prefer fusion
or implants depending on the stage of the
deformity. It is likely the debate will continue
and should. To complicate matters even farther,
there is always the argument as to which came
first the chicken or the egg. Does equinus cause
the dorsiflexion or is equinus a secondary
deformity in and of itself. I appreciate the
feedback.

Don Peacock, DPM, Whiteville, NC,
peacockdpm@gmail.com

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