Would a Jones Suspension be indicated for 1st metatarsal head plantar callus with transverse skin fissuring just proximal to the 1st metatarsal head? I'm thinking that the pathomechanics of this lesion is plantarflexion of the 1st ray at some point in the gait cycle. Elevating the 1st ray and stabilizing the 1st MTPJ might possibly resolve this lesion. Anyone have an idea about the rationale for this procedure in this case?

The other procedure to consider is the peroneal stop procedure. The effect is to weaken the peroneus longus plantar flexion of the 1st ray.  I recall many years ago a lecture by Steve Smith concerning this but I do not recall the details and indications for it.

Jones suspension is classically used for IPJ arthritis and to stabilize the IPJ and 1st MTPJ affected by muscle imbalance (hallux malleus).

I will post the x-rays later.  Unfortunately the patient is not available for a photo of the foot. The 1st MTPJ area is noticeably thicker in girth than the other foot.  The plantar callus was long standing when I saw it initially.  The skin fissure is transverse just proximal to the joint extending along the plantar-medial aspect of the 1st metatarsal head.

When I push up on the 1st metatarsal head the hallux does not plantarflex as much as the contralateral hallux.

So again, anyone have an idea about the rationale for these procedures in this case?

Is it possible for you to take a photo of the foot, particularly showing the plantar skin fissuring that you describe proximal to the met head weight bearing surface ?  You can insert the photo right into a new Comment, or select Edit Post on your first comment above and click the Insert Picture Button there .

Thanks,

Alan Sherman, DPM, CCMEP
CEO, PRESENT e-Learning Systems

The key with determining the efficacy of the Jones is going to be whether or not the 1st ray plantarflexion is flexible.  Is there an overall cavus foot apart from the 1st ray?  I, agree, a picture wold be helpful.  Is there Hammering of the hallux?  Increased submet 1 pressures may be due to retrograde plantarflexory forces.  if that was the case i would recommend a Hallux IPJ arthrodesis to reduce those pressures (possibly in conjunction with the jones).  If there is more of a global cavus, you might have to institute further tendon balancing or osteotomies depending on the apex of the deformity.

This is a patient with a flexible, plantarflexed 1st ray where i utilized a  jones tenosuspension to offload this sub 1st MPTJ ulceration.  With dorsiflexion of the first ray, his ulceration started to heal, and he has done well post-operatively.  We have also modified his orthotics to adjust for his modified biomechanics, and he is doing well.

I know John Steinberg at Georgetown has utilized this recently with success....he had a poster at the APMA conference that is featured in this month's (Jan-Feb 2010) JAPMA, although it's not up online yet.

For conservative treatment: If the first ray is really flexible, I have found that most of my patients with this symptom have a plantarflexed forefoot. This in turn causes a functional equines or what I refer to as Talo-Tibia Impingement Syndrome. If that is the case then a heel lift will help off weight the forefoot during gait and when combined with a strong arch support the callus and fissure heals.

I think Ryan hit it on the head in his posting. Without examination of the patient and reviewing radiographs It would be difficult to consider treatments with correlation to criteria evaluation and the procedure selection(s) but here goes anyway....
1. Is the plantarflexion of the first metatarsal of a flexible or rigid nature?;
2. Is there a hallux malleus deformity and concominant interphalangeus arthritic condition of the IP joint of the hallux contributing to the deformity?;
3. Is there a hypertrophic sesamoid with arthritic and fragmentary changes?;
4. Is there an inherent weakness of the flexoral tendons to suggest a tear?;

That being said....what are the options?
1. My feeling is that if the deformity is of a rigid nature without the evidence of (2) or (4), a dorsiflexory osteotomy of the first metatarsal head or base may work just fine. Addressing the any peroneus longus contracture via a lengthening procedure would be contingent on intra-operative findings. 
2. If the deformity is flexible with evidence of (2) or (4), a Jones Suspension Procedure can be considered.
3. If the ulceration is due to the presence of hypertrophic fragmented sesamoids, a "planing" or removal may be considered with capsular-tendon work at the 1 MPJ if a tibial sesamoid is excised with appropriate orthoses to address the possible compensatory effects of such a surgery;
4. If there is a mild to moderate extensor contracture, utilization of a tendon lengthening of the long extensor tendon may be needed as part of your overall correction;
5. The presence of dorsal contracture of the 1 MPJ with arthrosis and pain may warrant  a long extensor tendon lengthening with arthrodesis or Keller arthroplasty contingent on bone stock and patient activity level.