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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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