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#4 Surg > 57 and 58 - Surgical Treatment of Digital Deformities > Flashcards

57 and 58 - Surgical Treatment of Digital Deformities Flashcards

1
Q

Key words

A
  • PIPJ Fusion, arthroplasty, flexor tendon transfer, Weil osteotomy
  • Make sure you read your surgery text on hammertoe correction!!!!
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2
Q

MPJ Anatomy

A
  • YOU NEED TO KNOW THIS FOR INTERVIEWS
  • Need to know this in order to be effective
    at surgery so we do no harm the other structures
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3
Q

Digital deformities

A
    1. Hammertoe
    1. Claw toe
    1. Mallet toe
    1. Curly toe
    1. Adductovarus toe (congenital overlapping 5th)
    1. Crossover 2nd toe
    1. Floating Toe
    1. Flail Toe
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4
Q

Planes of Digital deformities

A
  • Sagittal
  • Transverse
  • Frontal
  • Combination
  • Example of 3rd digit x-ray: lateral deviation in the transverse plane, plantarflexed in the sagittal plane, inverted in the frontal plane
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5
Q

Digital deformity etiology: Biomechanical (3)

A
  • Flexor Stabilization (MOST common)
  • Flexor Substitution (LEAST common)
  • Extensor Substitution
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6
Q

Flexor Stabilization (MOST common)

A 
o	Pronation (can initially try to control pronation with orthotic) 
o	Flexors fire earlier and stay contracted longer to stabilize, “excessive gripping”
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7
Q

Flexor Substitution (LEAST common)

A

o Flexors gain advantage over interossei

o Deep posterior and lateral muscles attempt to make up for weak gastro-soleal complex

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8
Q

Extensor Substitution

A

o Pes Cavus, Neuromuscular, Equinus (these will NEED to be corrected as well)
o Decrease/resolve with WB initially - Initially hammer toes are only swing phase
o Seen in SWING phase, won’t see this in WB in the early stage, so orthotics will not work

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9
Q

Digital deformity etiology

A
  • Equinus
  • Long toe (long 2nd metatarsal, shoe gear will crunch toe, weakens plantar plate, increased WB of 2nd metatarsal, further weakens plantar plate – cannot straighten toe)
  • Bunion
  • Tight shoes?
  • Stockings?
  • Trauma - pre-dislocation syndrome or plantar plate injury
  • ***Key take home – must do full MS/BM exam on every patient to recognize associated factors – Don’t just treat the “symptom” treat the “disease”
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10
Q

Adductovarus 5th toe – VERY COMMON

A
  • Can be associated with 4th also
  • Transverse and frontal plane deformity
  • Associated with flexor stabilization
  • Can also have sagittal plane hammer/clawtoe of 5th
  • Weak/absent quadratus plantae?
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11
Q

Symptoms of adductovarus 5th toe

A
  • Heloma durum on the 5th metatarsal IPJ (rubs in shoes)
  • Heloma molle (soft corn) in the 4th interspace due to increased pressure
  • Nail complaints
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12
Q

Congenital overlapping 5th toe

A
  • Congential digiti minimi varus
  • Usually hereditary
  • Transverse, sagittal and frontal plane deformity
  • May have MPJ subluxation/dislocation
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13
Q

Symptoms of congenital overlapping of the 5th toe

A
  • Dorsal irritation

- Heloma durum/molle

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14
Q

“Curly toes”

A
  • Clinodactyly
  • Frontal and transverse planes
  • Congenital underlaping near digits, flexion and varus rotation of DIPJ
  • In severe cases the PIPJ is involved, usually bilateral
  • We will not do any surgical correction until they have ossification of the phalanges
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15
Q

Overlapping 2nd toe

A
  • Plantar plate and tendons slip medially or laterally
  • Plantar plate or collateral partial tear
  • Sagittal and transverse deformity
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16
Q

Floating toe

A
  • Does not purchase ground – usually used to describe toe that is still primarily rectus in transverse plane
  • Iatragenic – Weil osteotomy or pin positioning
  • Plantar Plate rupture (predislocation syndrome)
  • Secondary to brachymetatarsia
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17
Q

Flail toe

A
  • Does not purchase the ground- “floppy”
  • Iatrogenic – aggressive arthroplasty of 5th digit
  • Too much bone has been taken off and the 5th digit will dislocate
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18
Q

Syndactylization

A
  • Attach the flail toe to the stable toe next to it

- This is one of the go-to procedures for a flail toe

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19
Q

Components of clinical exam

A
  • Perform Weightbearing and Nonweightbearing
  • Flexible or reducible
  • Note location of hyperkeratotic lesions
  • Nail changes
  • Assess MPJ stability
  • Neurovascular status of the digit(s) – KNOW THE NORMALS ***
  • Neurologic concerns? May not know they are putting pressure on the toes
  • Other digital deformities
  • Metatarsal length concerns (long or short), metatarsal dorsiflexion or plantarflexion
  • Hallux abducto valgus with metatarsal primus adducto valgus
  • Equinus? Cavus? Pronated? Weakness?
  • Very important to assess and address to have good long term outcome. Don’t want to get too focused on visible deformity and miss the big picture.
  • ***The digital deformities is most likely just a “symptom” of the overall biomechanical problem
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20
Q

Flexible or reducible

A

o Flexible means you can get it to go straight, rigid means you cannot

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21
Q

Nail changes

A

o Nail changes occur because the 2nd toe is first to contract, so it starts to rub and causes a hypertrophy
o If you only have only a 2nd toe with it, it is likely not fungus, but a biomechanical cause

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22
Q

Assess MPJ stability

A

o Vertical stress test – Thompson and Hamilton or Lachman test

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23
Q

Neurovascular status of the digit(s) – KNOW THE NORMALS ***

A

o Macrovascular vs. microvascular – very important to think about because your patient could have good DP and TP blood flow, but poor microcirculation – it is NOT just about feeling pulses… Also cap refill, hair growth, transcutaneous O2 pressure, digital pressure
o **Transcutaneous oxygen pressure NORMAL = 60 mmHg, min of 40 mmHg healing
o **Digital pressure NORMAL = 30 is the cutoff for healing, ideally it should be 80-100, simplistic way to remember it is 100 mmHg, 100% chance of healing – if you’re going to do an elective procedure, you should have an 80% chance of healing so 80 mmHg

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24
Q

Kelikian push up test

A
  • 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
  • DIPJ, PIPJ, MTPJ or a combination
  • This is important for conservative treatment options because if their toes go straight with a Kelikian push up test, then a metatarsal pad in an orthotic can be effective
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25
Q

Retrograde buckling

A
  • Results in continued stretch/strain to plantar plate

- Increased pressure to plantar metatarsal head (Metatarsalgia, Hyperkeratosis formation)

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26
Q

Non-Surgical treatment

A
  • Will not resolve deformity

- Only treats the symptoms

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27
Q

Non-surgical treatment options

A
  • Crossover taping
  • Toe Splints
  • Function vs. Accomodative Orthotics with modifications (met pad/bar, met head cut out)
  • Padding
  • Accommodative foot gear (sandals, extra depth, supportive)
  • Oral anti-inflammatories (pain only)
  • Conservative treatment is not always benign - Watch skin closely, consider neurovascular status
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28
Q

Crest pad

A
  • For extensor substitution and claw toe deformities
  • Takes pressure off of distal digits
  • Does not straighten the toes
29
Q

Budin splint

A
  • For Flexor stabilization and substitution
  • Hold digit rectus, take strain off of plantar plate
  • Works best with minimal/flexible deformity
  • Useful for pre-dislocation syndrome
  • Will not work for Extensor substitution
30
Q

Crossover taping

A
  • Works the same as Budin splint

- Watch skin

31
Q

Surgical procedures

A
  • Surgical Procedures: Decision Based on Etiology, Entire Exam and Patient Risk Factors
  • Soft Tissue (Flexible deformity) - Flexor Release, Extensor Lengthening (Ext Sub), Capsulotomy, Flexor Transfer, Syndactyly
  • Arthroplasty (just means you are altering a joint) - With resection or without resection, With pinning or without pinning
  • Inter-Phalangeal Arthrodesis - Internal K-wire or External K-wire, Fusion device (smart toe, protoe screw, etc)
  • MPJ procedures - Release vs Plantar Plate Repair, Arthrodesis
  • Joint replacement devices
  • Condylectomy/Exostectomy - Removing any bony prominence
  • Metatarsal head resection (Rheumatoid) – we will not talk about this today
32
Q

Treatment based on etiology

A

Overload
o Lateral weight transfer (Lapidus or First MTPJ Fusion, Osteotomy of Lesser Metatarsal)
o Intrinsic weakness and loss of stabilization (PIPJ Fusion & MTPJ Release, Long Flexor Transfer)
o Equinus (Posterior Lengthening)

33
Q

Anatomic result of overoad

A

Degeneration
o Resection, Replacement, Fusion

Plantar Plate Insufficiency
o Repair
o MTPJ release, FDL Transfer, PIPJ Fusion

34
Q

Contraindications to surgical correction of digital deformity

A
  • Active soft tissue infection (need to treat the infection first)
  • Impaired vascular status
  • Impaired neurological status?
  • Co-morbid medical conditions
  • Cosmesis??? Some say absolutely not and some make a living off of it… Need to determine how much risk you can assume - The patient could come in with no pain and leave with pain
35
Q

Arthroplasty (without fusion)

A
  • Remember arthroplasty just means you’re doing something to the joint… If you mean a resection, you need to specify it
  • An arthroplasty procedure is for flexible to semi-rigid deformities
  • Due to the 5th digit and 5th MTPJ having its own axis of motion, resection arthroplasty (resect the head of the proximal phalanx) is recommended over arthrodesis (fusing the joint)
  • A resection arthroplasty shortens the toe and relaxes soft tissue

***NOTE: the deformity will potentially will recur if deforming force is not corrected
o This procedure does not create toe to rigid lever arm
o Loading phenomenon
o Do not recommend except for in isolated cases
o Loss of stability/flail toe if aggressive resection has occurred

36
Q

Why does a PIPJ fusion work to decrease recurrence of a hammertoe?

A
  • You no longer have a weak point where you can get an apex
  • Fusion here creates a rigid lever arm
  • When the flexor contracts, it will only work at the MPJ (where it is supposed to work),
  • Distal toe will be a mallet toe – complication with hammertoe surgery
37
Q

Post-operative management – Arthroplasty

A
  • Apropulsive shoe (post-op shoe) weight bearing for 3-4 weeks
  • Avoid excessive dorsiflexion or contracture for 2 months
38
Q

Arthrodesis of the PIPJ

A

Benefits
o Converts toe to rigid lever
o Done in patients whom intrinsic muscle function has been lost
o Provides stable lever arm
o Decrease risk of recurrence
o Transfers function of flexor to the MPJ

Can lead to a mallet toe

39
Q

Surgical question: What is the benefit of a chevron fusion over an end to end?

A
  • The end-to-end procedure will be able to rotate in the frontal plane
  • Chevron has increased bone healing due to increase bone contact
  • End-to-end has really good success rates, so most people don’t do chevron because it’s harder
40
Q

Hammertoe correction: Best approach in a stepwise manner

A

Sequential Release (not the same for every patient/surgeons)
o Skin incision (from just proximal to MPJ to just beyond PIPJ)
o PIPJ extensor tenotomy and capsulotomy
o Resection arthroplasty (to prepare for arthrodesis: End to end, Chevron, peg-in-hole)
o Release of extensor expansion/hood
o MPJ capsulotomy(dorsal and/or medial/lateral)
o Plantar plate/capsule release with McGlamry elevator (looks like a melon baller)

  • Kelikian “push-up” test performed after each step*
  • Make sure address all toes with deformity, or the others may become worse
41
Q

Retrograde K-wire fixation

A
  • Fixation for arthrodesis

- Stabilize MPJ after capsulotomy

42
Q

Post-op

A
  • WBAT to heel in postoperative shoe or boot- apropulsive gait
  • Pins in 6 weeks ideally (4-6)
  • Pull out in the office
  • Transition to athletic shoe as tolerated
  • Resume all activity ~ 10 weeks
43
Q

Post-operative management

A
  • 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
44
Q

Fixation of arthrodesis of PIPJ

A
  • Most common is a K-wire (0.062, 0.045 (more likely to break), Threaded K-wire (IM rod))
  • Screw
  • Compression staple
  • Interlocking component systems
  • Absorbable K-wire
  • Memory metal devices
45
Q

QUESTION Why must I pin across the joint in one, but not the other? How do I know assess this pre-operatively?

A
  • If you didn’t have to release the MPJ (the deformity was corrected before you got to that point in the progression of surgical correction) the K wire does not have to cross the MPJ
  • If you had to release the MPJ in order to correct the deformity, the MPJ is now unstable and you need to insert the K wire across the MPJ to stabilize it during the post-operative period
  • Pre-operative and intra-operative assessment is done with the Kelikian push up test
46
Q

Isolated flexory tenotomy goals

A

This is really only done in two situations
o Young, active patient with an entirely flexible hammer toe deformity (highly reducible)
o Really high risk patient in which I want to make the smallest incision as possible

It’s an alternative to arthroplasty/pinning for flexible hammertoe correction in some patients

Indications:
o Flexible (or semi rigid) contractures of the IPJ of digits
o Distal callus or ulcer, no MPJ dorsal contracture
o Patients with medical or age related concerns for recovery

47
Q

Isolated flexory tenotomy procedure

A
  • 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
48
Q

Recovery from isolated flexory tenotomy

A
  • Light bandage for 3 -4 days
  • Remove bandage and shower @day 4
  • Activity as tolerated in sandal of PO shoe
  • Sutures removed between 3 and 4 weeks
49
Q

Extensor tenotomy procedure

A
  • Not done very often
  • For flexible to semiflexible deformities (TEMPORARY fix)
  • For pediatric and elderly where a more definitive surgery is contraindicated
  • 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
50
Q

Extensor tenotomy and capsulotomy

A
  • Semi-flexible deformity, elderly patient
  • Done at the MTPJ
  • Linear incision dorsal overlying the MTPJ
  • Insert blade; blade inferior to tendon and turn upwards towards extensor tendon and distract and plantarflex toe, and extensor tendon is transected.
  • Sectioning of the MTPJ capsule dorsally, medially, and/or laterally.
51
Q

Flexor tendon transfer – 2 incision technique

A
  • Girdlestone or Girdlestone-Taylor
  • Two incisions
  • One over dorsum of the base of proximal phalanx
  • One on the side or plantarly on the toe for visualization
  • From this second incision, the flexor tendon is transected as far distal as possible and split longitudinally
  • Slips are passed on either side of proximal phalanx
  • The tendon slips are crossed and tightened and sutured together.
  • Can also be inserted through drill hole in phalanx or anchored to phalanx (interference screw)
52
Q

Flexor tendon transfer procedure

A
  • The transferred tendon takes over the function of the lost intrinsics
  • Can cause a toe to look fat and mildly elevated
  • Can cause the DIPJ to buckle
  • Most surgeons prefer PIPJ arthrodesis in conjunction to convert long flexor into an effective plantarflexor at the MTPJ.
  • Can do through dorsal or lateral incision alone
  • Primarily corrects Sagittal Plane
  • How can this be used to correct the transverse plane?
53
Q

Flexor tendon transfer notes

A
  • Educate patients that toe will be “stiff” afterwards (can be a possible downfall)
  • This stiffness is what stabilizes the MPJ and prevents recurrence
  • Transfers function of flexor to the MPJ, eliminates risk of mallet toe
  • NOTES: We take the flexor tendon and in some way or form, bring the slips up and around onto the top of the proximal phalanx to hold it stable
54
Q

Effect of long flexor transfer

A
  • Long flexor transfer leads to dynamic stabilization of the MTPJ, but NOT universally successful

Iglesias et al JAPMA 2012
o 86-91% Patient satisfaction reported in a systematic review
o Did not report on position or function

Bouche JFAS 2008
o 73% Success with combination of procedures
o Most of the available studies combine multiple procedures making it impossible to determine the actual effect or non-effect of FDL transfer

55
Q

Post-operative management – FDL transfer

A
  • Non-weightbearing for 3-4 weeks to allow tendon to fibrose

- Avoid dorsiflexion and contracture for 2 months, consider protecting with splint

56
Q

Effect of plantar plate repair

A
  • Major stabilizer of the MTPJ and common component of second toe dislocation syndrome
  • Why does it rupture? Acute trauma (10%) or Progressive degeneration secondary to abnormal mechanical forces (overload)
  • Repair of the plantar plate

Does it make sense to repair the PP without addressing the abnormal mechanical forces that caused the degeneration and rupture? NO

57
Q

MRI of plantar plate

A
  • Sqourpian (Arthrex) and Hattrick – youtube videos of indirect repair (since they are done dorsally – plantar approach is called a direct repair)
  • MRI can certainly diagnose PP tear, this has been shown in multiple studies
  • Ultrasound can diagnose PP tear as well

Tough questions (we won’t really get into this today)
o Do we need to see the tear to know what the diagnosis is when we have a subluxed MTPJ with plantar pain?
o Does seeing the tear lead to more effective treatment?
o Does seeing the tear allow us to determine what caused the overload and subsequent degeneration and tear?
o Is MRI becoming a replacement for sound biomechanical examination, understanding and diagnosis?

58
Q

Adjunctive procedures

A
  • Plantar Plate Repair: Plantar approach or dorsal approach
  • Metatarsal osteotomy (to shorten): Weil or Z osteotomies (Recall that a long metatarsal can be an etiology of hammer toes, so consider this)
  • Skin Plasty
59
Q

Treatment principles for adjunctive procedures

A

***Do a complete evaluation of all toes
o Loading phenomenon can make minor contractures worse
o If you repair one severe hammer toe, the 2 or 3 toes next to it which have a mild hammer toe will now bear more weight and will now have a severe hammer toe post-op, so you may need to repair them at the same time

  • **Repair the HAV with MPAV (Bunion procedure to stabilize)
  • **Address the equinus
60
Q

Effect of first MTPJ fusion

A
  • Nicholas et al JFAS 2005: “Creation of a stable medial buttress may protect the lesser digits”
  • Harrison JBJS 1963, Coughlin JBJS 2000: “Lesser digital deformities improved spontaneously after MTPJ fusion”
  • Thorardson FAI 2002: “Maintaining the first MTPJ during PMR resulted in HAV and recurrence of digital deformity”
  • ***Bottom Line: First MTPJ arthrodesis has a stabilizing and protective effect on the lesser MTPJs
61
Q

Gastroc recession

A
  • Decrease in compensatory STJ pronation
  • Decrease in medial column supination
  • Decrease in lateral MTPJ loading
  • Well documented to decrease forefoot loading
62
Q

Adductovarus of 5th toe adjunctive procedure

A
  • An adjunctive procedure we often do with an adductovarus 5th toe is a derotational skin plasty
  • This means that we are making a cut in the tissue such that after removing a portion of the head of the proximal phalanx, we will also remove an ellipsoid shaped portion of the tissue
  • This tissue is located from medial dorsal to proximal lateral plantar***
  • When you close this incision, it swings the toe up and around (hinge-axis concept)
  • KNOW THIS PROCEDURE – IT WILL COME UP AGAIN
63
Q

Adductovarus of 5th toe adjunctive procedure (from slides)

A

From slides…
o 5th Digital derotational arthroplasty
o Dorotationsl skin plasty with resection arthroplasty of head of proximal phalanx
o Oriented distal medial dorsal to proximal lateral plantar
o Phalangectomy, remove middle phalanx if small or Condylectomy if large
o This is a “hinge-axis”

64
Q

Complications (didn’t talk about this much)

A
  • Swelling
  • Recurrence
  • Vascular compromise
  • Flail toe
  • Nonunion
  • Pain
  • Hardware failure
  • Infection
  • Metatarsalgia
  • Numbness
  • Lack of toe purchase-Floating toe
  • Medial or lateral deviation at PIPJ
  • Short digit
  • Stiffness
  • Post-inflammatory rubor
65
Q

**Sausage digit ** KNOW THIS

A

Definition of a sausage digit
o Swelling that persists beyond first 3-4 months

Causes of a sausage digit
o Damage to lymphatics or venous system (via surgical technique or tourniquet effect with bandaging)
o Non-union /pseudoarthrosis of arthrodesis site
o Infection

66
Q

VASCULAR COMPROMISE “THIS IS HUGE”

A
  • Know the difference between a white toe and a blue toe
67
Q

WHITE TOE

A
  • “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 following surgery
  • Make sure cap refill before recovery!
  • KNOW THIS: A white toe turns into a dead toe
68
Q

Treatment for white toe (KNOW ALL OF THESE)

A 
o	NO ICE, loosen bandage, warm blanket
o	Dependent position/massage
o	Move/rotate k-wire
o	Pull k-wire – “a floppy toe is better than a dead toe”
o	Alpha blocker (phentolamine/regitine injection)
o	Oral vasodilators (nifedipine)/topical
o	Sympathetic nerve block
o	Surgical exploration
69
Q

Blue toe

A
  • Venous congestion, from excess blood coming into the area and not being able to get back out
  • This is a dissecting hematoma – can tell if the toe is warm and pink immediately after surgery then becomes more blue in the post-op period and you KNOW you had good capillary refill before sending your patient to recovery
  • Do not treat with vasodilators – can make worse
  • May eventually get eschar and sloughing, but underlying tissue is 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

#4 Surg (14 decks)

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