57/58: Surgical treatment of digital deformities - Feilmeier Flashcards
MPJ anatomy review
flexor stabilization vs. flexor substitution vs. extensor substitution review
-
Flexor Stabilization
- Pronation
- Flexors fire earlier and stay contracted longer to stabilize
- “Excessive gripping”
- Most common
- Pronation
-
Flexor Substitution
- Flexors gain advantage over interossei
- Deep posterior and lateral muscles attempt to make up for weak gastro-soleal complex
- Least common
- Flexors gain advantage over interossei
-
Extensor Substitution
- Pes Cavus, Neuromuscular, Equinus
- Decrease/resolve with wt bearing initially
s/s hammertoe
- •Heloma durum (corn/callous)
- •Hyperkeratosis sub metatarsal head
- •Metatarsalgia
- •Subluxation, dislocation
- •May be flexible or rigid
MIPJ extension
PIPJ flexion
DIPJ extension
hammertoe
s/s claw toe
- Hyperkeratosis and metatarsalgia
- Subluxation, dislocation
- When condition is flexible, toes straighten on weightbearing but are contracted during swing phase
- Hyperkeratosis at distal tip of toe
MPJ extension
PIPJ flexion
DIPJ flexion
claw toe
s/s mallet toe
- Dystrophic nail
- Hyperkeratosis at distal tip of toe
DIPJ flexion
plantrflexed distal phalanx
mallet toe
describe adductovarus 5th toe
- Transverse and frontal plane deformity
- Associated with flexor stabilization
- Very common
- Can also have sagittal plane hammer/clawtoe of 5th
- Weak/ absent quadratus plantae?
- s/s heloma durum/molle, nail complaints
“curly toes”
clinodactyly
- Frontal and transverse planes
- Congenital
- Underlap near digits
- Flexion and varus rotation of DIPJ
- In severe cases the PIPJ is involved
- Usually bilateral
overlapping 2nd toe
- Plantar plate and tendons slip medially or laterally
- Plantar plate or collateral partial tear
- Sagittal and transverse deformity
floating vs. flail toe
(may be used interchangeably)
- floating toe
- Does not purchase ground
- Usually used to describe toe that is still primarily rectus in transverse plane
- Iatragenic: Weil osteotomy, Pin positioning
- Plantar Plate rupture: Predislocation syndrome
- Secondary to brachymetatarsia
- flail toe
- Does not purchase the ground- “floppy”
- Iatrogenic: Aggressive arthroplasty, 5th digit
why do you see nail changes with toe deformities?
nail hypertrophy (2nd toe first ususally) due to rubbing
lachman drawer test
- > 50% dorsal displacement of the base of the proximal phalanx on the head of the metatarsal is positive for plantar plate laxity/rupture
- Evaluates the structural integrity of the plantar plate
thompson and hamilton sign
- Pain with pure vertical force across the MPJ
- Palpable prominent base of proximal phalanx dorsally
- Sign of MPJ instability
kelikian push up test
- Load plantar forefoot- push up on metatarsal heads (simulate wt bearing)
- Watch what happens to the digits at MPJ, PIPJ
- Degree of fixed (structural) deformity is determined by the “push-up” test
- Determines what needs to be done and where
- Does MPJ need to be released?
- Soft tissue versus bone
describe retrograde buckling
- Results in continued stretch/strain to plantar plate
- Increased pressure to plantar metatarsal head
- Metatarsalgia
- Hyperkeratosis formation
crest pad
- For extensor substitution and claw toe deformities
- Takes pressure off of distal digits
- Does not straighten the toes
indications budin splint
flexor stabilization and substitution
works best with flexible deformity
can also be used for pre-dislocation syndrome
will not work for extensor substitution
resection arthroplasty
Simply means joint work- make sure you specify if “resection”
contraindications to surgical correction of digital deformity
- Active soft tissue infection
- Impaired vascular status
- Impaired neurological status?
- Co-morbid medical conditions
- Cosmesis???
why should the 5th digit be corrected with arthroplasty over arthrodesis?
Due to the 5th digit and 5th MTPJ having its own axis of motion, resection arthroplasty is recommended over arthrodesis
most common way to fix a hammertoe
PIPJ fusion
- creates rigid lever arm
- contraction of flexor now works at MPJ (not at PIPJ) and at DPJ (–> malletoe)
benefits of arthrodesis of PIPJ
- Converts toe to rigid lever
- Done in patients whom intrinsic muscle function has been lost
- Provides stable lever arm
- Decrease risk of recurrence
- Transfers function of flexor to the MPJ
what is the benefit of a chevron fusion over an end to end?
chevron reduces rotational forces and increase surface area (increased healing)
both can move distally but if chevron moves distally there might still be bone touching
(-) chevron causes additonal shortening
stepwise approach to hammertoe correction
**
- skin incision
- PIPJ extensor tenotomy and capsulotomy
- resection arthroplasty
- relase of extensor expansion/hood
- MPJ capsulotomy (dorsal and/or medial/lateral)
- plantar plate/capsule relase with McGlamry elevator
kelikian push up test performed after each step
describe retrograde k-wire fixation
- Fixation for arthrodesis
- Stabilize MPJ after capsulotomy
post op care hammertoe arthrodesis
- WBAT to heel in postoperative shoe or boot- apropulsive gait
- Pins in 6 weeks ideally (4-6)
- 0.062 K wire most commonly
- Pull out in the office
- Transition to athletic shoe as tolerated
- Resume all activity ~ 10 weeks
- May consider digital splint in evening for 4-6 weeks after wire removal
- Avoid activities that will cause contracture of toe
- Walking up hills, walking on wet sand, squatting and tight pantyhose for 2 months after healed
indications for an isolate flexory tenotomy
- Flexible (or semi rigid) contractures of the IPJ of digits
- Distal callus or ulcer
- No MPJ dorsal contracture
- Patients with medical or age related concerns for recovery
goal: Present an alternative to arthroplasty and pinning for flexible hammertoe correction in a selected patient population
describe the isolate flexory tenotomy procedure
- Flexor tendon release from plantar approach @ level of deformity
- Plantar IPJ capsulotomy if needed
- Dorsal Suspension stitch
- 0-2.0 non-absorbable suture (prolene) dorsally through the extensor tendon
- Just proximal to the nail and at the level of the MPJ
temporary fix for pediatric and elderly where a more definitive surgery is contraindicated
extensory tenotomy
- Proximal to MPJ, small stab skin incision is made
- Knife blade inserted below tendon and rotated perpendicular to it
- Toe is plantarflexed over blade, cutting it
- Loading phenomenon, so perform on all lesser toes
- (one tendon going to all four toes- anatomy!)
indications for flexor tendon transfer
- Floating toe
- Metatarsalgia
- Dorsally contracted MPJ
- Plantar Plate Tear
- When flexor has mechanical advantage over intrinsics
transfers function of flexo rto MPJ, eliminating risk of mallet toe but toe will be stiff afterwards, does nothing to PIPJ
effects of gastroc recession
- Decrease in compensatory STJ pronation
- Decrease in medial column supination
- Decrease in lateral MTPJ loading
- Well documented to decrease forefoot loading
describe 5th digital derotational arthroplasty
- Dorotationsl skin plasty with resection arthroplasty of head of proximal phalanx
- Oriented distal medial dorsal to proximal lateral plantar
white toe vs. blue toe
- White Toe” (could appear blue)
- Very contracted toes pre-op may go through vasospasm post-op when toe is straightened
- Toe cold, no capillary refill
- Make sure cap refill before recovery!
- Treatment:
- NO ICE
- 1.loosen bandage, 2.warm blanket, 3.dependent position/massage, 4.move/rotate k-wire, 5.pull k-wire – “a floppy toe is better than a dead toe”, 6.alpha blocker (phentolamine/regitine injection), 7.oral vasodilators (nifedipine)/topical, 8.sympathetic nerve block, 9.surgical exploration
- Blue toe
- Venous Congestion
- Dissecting hematoma
- Toe warm and pink immediately, then becomes more blue.
- Good capillary refill
- Do not treat with vasodilators- can make worse
- May eventually get eschar and sloughing, but underlying tissue healthy.
- Make sure you see capillary refill to digit prior to leaving OR so you know this is a “blue” toe and not a “white” toe.
