57/58: Surgical treatment of digital deformities - Feilmeier

Question 1

MPJ anatomy review

Answer 1

Question 2

flexor stabilization vs. flexor substitution vs. extensor substitution review

Answer 2

• Flexor Stabilization
  
  • Pronation
    
    • Flexors fire earlier and stay contracted longer to stabilize
    • “Excessive gripping”
  • Most common
• Flexor Substitution
  
  • Flexors gain advantage over interossei
    
    • Deep posterior and lateral muscles attempt to make up for weak gastro-soleal complex
  • Least common
• Extensor Substitution
  
  • Pes Cavus, Neuromuscular, Equinus
  • Decrease/resolve with wt bearing initially

Question 3

s/s hammertoe

Answer 3

• •Heloma durum (corn/callous)
• •Hyperkeratosis sub metatarsal head
• •Metatarsalgia
• •Subluxation, dislocation
• •May be flexible or rigid

Question 4

MIPJ extension

PIPJ flexion

DIPJ extension

Answer 4

hammertoe

Question 5

s/s claw toe

Answer 5

• 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

Question 6

MPJ extension

PIPJ flexion

DIPJ flexion

Answer 6

claw toe

Question 7

s/s mallet toe

Answer 7

• Dystrophic nail
• Hyperkeratosis at distal tip of toe

Question 8

DIPJ flexion

plantrflexed distal phalanx

Answer 8

mallet toe

Question 9

describe adductovarus 5th toe

Answer 9

• 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

Question 10

“curly toes”

Answer 10

clinodactyly

• Frontal and transverse planes
• Congenital
• Underlap near digits
• Flexion and varus rotation of DIPJ
• In severe cases the PIPJ is involved
• Usually bilateral

Question 11

overlapping 2nd toe

Answer 11

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

Question 12

floating vs. flail toe

(may be used interchangeably)

Answer 12

• 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

Question 13

why do you see nail changes with toe deformities?

Answer 13

nail hypertrophy (2nd toe first ususally) due to rubbing

Question 14

lachman drawer test

Answer 14

• > 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

Question 15

thompson and hamilton sign

Answer 15

• Pain with pure vertical force across the MPJ
• Palpable prominent base of proximal phalanx dorsally
• Sign of MPJ instability

Question 16

kelikian push up test

Answer 16

• 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

Question 17

describe retrograde buckling

Answer 17

• Results in continued stretch/strain to plantar plate
• Increased pressure to plantar metatarsal head
• Metatarsalgia
• Hyperkeratosis formation

Question 18

crest pad

Answer 18

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

Question 19

indications budin splint

Answer 19

flexor stabilization and substitution

works best with flexible deformity

can also be used for pre-dislocation syndrome

will not work for extensor substitution

Question 20

resection arthroplasty

Answer 20

Simply means joint work- make sure you specify if “resection”

Question 21

contraindications to surgical correction of digital deformity

Answer 21

• Active soft tissue infection
• Impaired vascular status
• Impaired neurological status?
• Co-morbid medical conditions
• Cosmesis???

Question 22

why should the 5th digit be corrected with arthroplasty over arthrodesis?

Answer 22

Due to the 5th digit and 5th MTPJ having its own axis of motion, resection arthroplasty is recommended over arthrodesis

Question 23

most common way to fix a hammertoe

Answer 23

PIPJ fusion

• creates rigid lever arm
• contraction of flexor now works at MPJ (not at PIPJ) and at DPJ (–> malletoe)

Question 24

benefits of arthrodesis of PIPJ

Answer 24

• 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

Question 25

what is the benefit of a chevron fusion over an end to end?

Answer 25

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

Question 26

stepwise approach to hammertoe correction

**

Answer 26

1. skin incision
2. PIPJ extensor tenotomy and capsulotomy
3. resection arthroplasty
4. relase of extensor expansion/hood
5. MPJ capsulotomy (dorsal and/or medial/lateral)
6. plantar plate/capsule relase with McGlamry elevator

kelikian push up test performed after each step

Question 27

describe retrograde k-wire fixation

Answer 27

• Fixation for arthrodesis
• Stabilize MPJ after capsulotomy

Question 28

post op care hammertoe arthrodesis

Answer 28

• 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

Question 29

indications for an isolate flexory tenotomy

Answer 29

• 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

Question 30

describe the isolate flexory tenotomy procedure

Answer 30

• 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

Question 31

temporary fix for pediatric and elderly where a more definitive surgery is contraindicated

Answer 31

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!)

Question 32

indications for flexor tendon transfer

Answer 32

• 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

Question 33

effects of gastroc recession

Answer 33

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

Question 34

describe 5th digital derotational arthroplasty

Answer 34

• Dorotationsl skin plasty with resection arthroplasty of head of proximal phalanx
• Oriented distal medial dorsal to proximal lateral plantar

Question 35

white toe vs. blue toe

Answer 35

• 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.