Fowler, J Bone Joint Surg Br 1959 - A Method of Forefoot Reconstruction

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A Method of Forefoot Reconstruction

Fowler·J Bone Joint Surg Br·1959·120 citations·Case series

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Fowler tested whether a forefoot reconstruction could relieve pain from irreversible claw toes with prominent metatarsal heads as an alternative to toe amputation. Preliminary case series of 20 patients treated by proximal phalangectomy, metatarsal head remodeling and plantar skin ellipse excision, followed a mean 2 years 3 months (range 1 to 4.5 years) for pain and activity.

Key Findings

All 20 patients reported significant pain relief and improved activity at mean 2 years 3 months.
Plantar callosities developed in 35% (7/20), all in patients not given postoperative metatarsal supports. None appeared before 6 months postoperatively.
Irregularly trimmed metatarsal heads led to recurrent pain needing further trimming. Excising all metatarsal heads completely caused forward-falling balance disturbance in 1 patient.
Tourniquet use caused proximal flap necrosis in 1 patient with atrophic rheumatoid tissues.
Significance: One of the oldest operations for the painful rheumatoid forefoot, it improved on Hoffman's plantar-incision head excision and on toe amputation by repositioning the plantar plate and fat pad beneath the remodeled heads with a more acceptable cosmetic result.

Board PearlThe Fowler procedure combines proximal phalangectomy and metatarsal head remodeling with plantar skin ellipse excision, which pulls the dorsally displaced fat pad back under the metatarsal heads.

A Method of Forefoot Reconstruction

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A Method of Forefoot Reconstruction

Fowler·J Bone Joint Surg Br·1959·120 citations·Case series

|

Fowler tested whether a forefoot reconstruction could relieve pain from irreversible claw toes with prominent metatarsal heads as an alternative to toe amputation. Preliminary case series of 20 patients treated by proximal phalangectomy, metatarsal head remodeling and plantar skin ellipse excision, followed a mean 2 years 3 months (range 1 to 4.5 years) for pain and activity.

Key Findings

All 20 patients reported significant pain relief and improved activity at mean 2 years 3 months.
Plantar callosities developed in 35% (7/20), all in patients not given postoperative metatarsal supports. None appeared before 6 months postoperatively.
Irregularly trimmed metatarsal heads led to recurrent pain needing further trimming. Excising all metatarsal heads completely caused forward-falling balance disturbance in 1 patient.
Tourniquet use caused proximal flap necrosis in 1 patient with atrophic rheumatoid tissues.
Significance: One of the oldest operations for the painful rheumatoid forefoot, it improved on Hoffman's plantar-incision head excision and on toe amputation by repositioning the plantar plate and fat pad beneath the remodeled heads with a more acceptable cosmetic result.

Board PearlThe Fowler procedure combines proximal phalangectomy and metatarsal head remodeling with plantar skin ellipse excision, which pulls the dorsally displaced fat pad back under the metatarsal heads.

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