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Fig. 45c2. Principle III – To reach a correct relative length of the metatarsals (metatarsal parabola). b) In
the medial oblique view.
1. The medial oblique view.
2. Metatarsalgia on the third ray: Same foot on dorso-plantar view. The third metatarsal has a correct length
comparatively to the second one. The Maestro line is correct. The explanation of this metatarsalgia location is
provided by the medial oblique view, which shows the relative excess of length of the third metatarsal.
3. Single second metatarsal osteotomy, resulting in excessive length of the third metatarsal. The corresponding
transfer metatarsalgia was relieved by a secondary Weil osteotomy.
4. Single second metatarsal well managed osteotomy: The second metatarsal remains slightly longer than the
third one. There is no transfer metatarsalgia.
Fourth Principle
The generous shortening
of the metatarsals
The fourth principle is to give more place to a
generous shortening of the metatarsals
(Fig. 45d1-2-3-4), resulting in a significant
widening of joint preservation.
This is certainly a point which is more difficult
to assimilate because first, previous techniques
of shortening were unpredictable, harmful,
invasive and because surgeons generally think
that the “less is the best”. In spite of this, my
observations and critique of the results show
clearly, strongly, obviously that the generous
shortening of the metatarsals provides a painless, harmless, reliable and elegant solution to
any severe deformity of the forefoot.
Eight Principles of Forefoot Reconstruction
All along this book, we already brought precisions about the amount of the required metatarsal shortening, clinically notably on the first
ray, by the MTP dorsal flexion, radiologically
thanks to the ms point (metatarsal shortening),
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which is the most proximal part of the first
phalanx bases, whatever the considered ray.
This amount of metatarsal shortening for
severe forefoot problems was determined not by
a prospective study, but by the observation of
Fig. 45d1. Principle IV – The place of a generous shortening of the metatarsals. a) In large deformities.
1, 2. In such forefoot deformity we regret not to have shortened the fifth metatarsal, for two reasons:
1) The correction (hallux valgus and hammertoes) should certainly be better because the shortening of the
metatarsals should be larger.
2) Some problems remain in the fifth toe in spite of its distal resection.
3, 6. Bilateral problem.
3, 4. We decided to make a larger shortening on the left foot because it was more deformed and because the
lesser metatarsals were longer (M2/M1 and Maestro line proximal from the fourth metatarsal center).
5, 6. Result for the same patient: On the left foot, where the shortening of the metatarsals was larger, both
postoperative period, deformity correction and joints mobility were significantly better than for the right foot.
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Forefoot Reconstruction
the results. Reliable and good results are significant according to this amount of shortening:
Less metatarsal shortening may be attractive
and is usually made by surgeons (and was made
by myself in my earlier experience) but the
results are significantly less and incomplete.
Additionally the metatarsal shortening
allows to preserve the length of the toes and the
toe joints so that the global foot length is not
diminished very much and the foot remains elegant: It is another way to approach the forefoot
problem, above all the severe disorders.
The frontier between moderate and severe
deformity is sometimes easy to delimit but
sometimes uneasy: In this case, we can say that
this frontier is much closer than what is usually
considered. In other words, when we are hesitating, the balance swings in the generous metatarsal shortening versus soft tissue and toes sur-
gery. We now have sufficient bilateral cases (one
example Fig. 45 IVa) to be sure of this.
Regarding this principle, the trophic troubles
or the patient age are also interesting: We usually
considered not to be invasive in such cases. Now,
on the contrary, we do a generous shortening of
the metatarsal even in these cases and the result
is excellent whatever the local troubles, the deformity, the age. For me it is a radical change in my
attitude. The result clearly shows that it is in fact
a significant improvement in the approach of
such severe deformities. The key of this generous
metatarsal shortening is, as called by L. S. Weil,
the longitudinal decompression notably of the
MTP joints, allowing a much better joint preservation than traditionally. Of course, this articular
preservation has limits and in this case, we do an
MTP fusion or head resection. We do this less
than usually, it is all!
Fig. 45d2a. Principle IV – The place of a generous shortening of the metatarsals. b) In severe forefoot
disorders. 1) The amount of shortening on the dorso-plantar X-ray view.
1. Focus on the first ray. Loss of MTP dorsal flexion in the correction handling and lateral subluxation of the
first phalanx which indicates the required shortening (ms point).
2. Focus on the lesser rays. Ms point located on the proximal part of the phalanx (on the most dislocated ray).
3. Focused both on first and lesser rays (ms point).
Eight Principles of Forefoot Reconstruction
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Fig. 45d2b. Principle IV – The place of a generous shortening of the metatarsals. b) In severe forefoot
disorders. 2) The amount of shortening on the medial oblique view.
For this patient, the metatarsal shortening is well assessed on the right foot (ms). On the left foot, the ms
point is uncertain and in this case, the medial oblique view is useful to accurately determine the ms shortening
point (overridding of the first phalanx).
Fig. 45d3. Principle IV – The place of a generous shortening of the metatarsals. c) Preservation of the
metatarsal heads.
1. Louis XVI, before and during his beheading: Did his head deserve this treatment?
2. In the same way, did this foot really deserve the head resections? (Sometimes replacing monarchy by
anarchy… Unfortunately, L. S. Weil born is 1.5 century too late!)
3. It is certain that in this foot the MTP joints could not be preserved, nor the metatarsal heads.
4. But, in this case, we preserved 4/5 of the heads. Is it not preferable, as far as we can do it?
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Forefoot Reconstruction
Fig. 45d4. Principle IV – The place of a generous shortening of the metatarsals. c) Postoperative aspects.
The foot is not very swollen, it is painful. The mobility is early recovered. The foot is relaxed and the patient too!
Fifth Principle
Single ray pathology
The fifth principle is, when the pathology only
affects one ray and the surgery doesn’t have to
jeopardize the other rays, to perform surgery
only on this ray! (Fig. 45e)
The only point we would like to emphasize
is to be sure that this one ray surgery will really
not really compromise the other rays (transfer
lesion). Once again, remember the level crossing
notice “a train should hide another one”.
Fig. 45e. Principle V – Nevertheless when there is no previous forefoot pathology, we have to respect
the preoperative anatomy.
In this example, there is an excessive length of the lesser metatarsal but without clinical signs: We firstly
performed a scarf osteotomy (but with M1 lowering).