Fowler describes a salvage operation for irreversible claw toe deformity with painful prominent metatarsal heads, proposed as an alternative to toe amputation. The technique combines proximal phalangectomy, metatarsal head remodeling, and plantar skin ellipse excision to reposition the weight-bearing fat pad. This is a preliminary report of the first 20 patients.
Before Fowler, the accepted salvage for irreversible forefoot deformity was toe amputation with metatarsal head trimming (Nissen, 1957). The mechanical problem with amputation is that it fails to reposition the plantar fat pad, which migrates further dorsally and leaves the remodeled heads unprotected — illustrated by Fowler's own photograph of a foot that remained painful after amputation.
When you plan forefoot reconstruction, two intraoperative steps are non-negotiable: establish the metatarsal parabola by shortening the longer rays, and remove a plantar skin ellipse to advance the fat pad beneath the remodeled heads. Bone remodeling without fat pad repositioning replicates the failure mode of amputation.
At every postoperative visit beyond 6 months, prescribe metatarsal supports regardless of symptoms. The callosity data make this mandatory. Every callosity in this series occurred in unsupported patients, and none appeared before 6 months.
Fowler's double-incision technique was later refined by Kates, Kessel, and Kay into a single plantar approach, and the long-term validity of forefoot arthroplasty was confirmed by Coughlin's 2000 series in JBJS-A. The fat pad repositioning principle Fowler established in 1959 remains the conceptual foundation of all subsequent forefoot arthroplasty techniques.
Fowler describes a salvage operation for irreversible claw toe deformity with painful prominent metatarsal heads, proposed as an alternative to toe amputation. The technique combines proximal phalangectomy, metatarsal head remodeling, and plantar skin ellipse excision to reposition the weight-bearing fat pad. This is a preliminary report of the first 20 patients.
Before Fowler, the accepted salvage for irreversible forefoot deformity was toe amputation with metatarsal head trimming (Nissen, 1957). The mechanical problem with amputation is that it fails to reposition the plantar fat pad, which migrates further dorsally and leaves the remodeled heads unprotected — illustrated by Fowler's own photograph of a foot that remained painful after amputation.
When you plan forefoot reconstruction, two intraoperative steps are non-negotiable: establish the metatarsal parabola by shortening the longer rays, and remove a plantar skin ellipse to advance the fat pad beneath the remodeled heads. Bone remodeling without fat pad repositioning replicates the failure mode of amputation.
At every postoperative visit beyond 6 months, prescribe metatarsal supports regardless of symptoms. The callosity data make this mandatory. Every callosity in this series occurred in unsupported patients, and none appeared before 6 months.
Fowler's double-incision technique was later refined by Kates, Kessel, and Kay into a single plantar approach, and the long-term validity of forefoot arthroplasty was confirmed by Coughlin's 2000 series in JBJS-A. The fat pad repositioning principle Fowler established in 1959 remains the conceptual foundation of all subsequent forefoot arthroplasty techniques.