Session III Lesser rays Mr. V. Dhukaram. Warwick Orthopaedics is a centre of excellence for...
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Transcript of Session III Lesser rays Mr. V. Dhukaram. Warwick Orthopaedics is a centre of excellence for...
Session III
Lesser rays
Mr. V. Dhukaram
Warwick Orthopaedics is a centre of excellence for research, teaching and development of the treatment of musculoskeletal disease.
I am delighted to welcome you all for the Warwick Cadaveric Foot and Ankle Surgery course. This course is designed to be practical with no formal lectures. We have put together the educational and product information for you to familiarise prior to the course which would be a valuable adjunct to the course.Vivek DHUKARAM
Patho-Anatomy of lesser toe deformities
Intrinsics(Lumbricals & Interossei) maintain MTPJ in neutral where long extensors and flexors act at IPJ
Muscle imbalance or intrinsic weakness lead to deformities
Lesser Toe DeformitiesDeformity MTPJ PIPJ DIPJ Model Clinical
picture
Hammer toe
Neutral/ hyper-extended
Plantar flexed
Neutral/ hyper-extended
Claw toe Hyper-extended
Plantar flexed
Plantar flexed
Mallet toe Neutral Neutral Plantar flexed
Curly toe Neutral / plantar flexed
Plantar flexed
Plantar flexed
Mallet toe
DIPJ Fusion technique -Transverse or longitudinal incisionExtensor tendon and release collateral ligamentsResect head of MP and curette base of DP articular surfaceRetrograde or Antegrade fixation from tip of toe to base of middle/proximal phalanx with 1.4/1.6mm k wire
1.4mm
Fixed Def. – DIPJ fusionFlexible – FDL tenotomy
Coughlin Operative repair of the mallet toe. FAI 16(3):109-116. 1995
Summary of Surgical treatment of Hammer toes & Claw toes
MTPJ PIPJ Recommendation
Flexible Flexible FDL transfer(Girdlestone-Taylor)/ Flexor tenotomy(FDL)
Flexible Fixed MTPJ release + PIPJ fusion
Sublux/Dislocate
Fixed Weils + PIPJ fusion, Stainsby (Prox. hemiphalangectomy)
Unstable FDL transferClaw toes will require additional DIPJ fusion/ tenotomy / FDL transfer depending on its flexibility
Girdlestone -Taylor (FDL transfer)
FDL to takeover the function of Intrinsics to maintain MTPJ in neutral
Flexor tenotomy Vs FDL transferFlexor tenotomy JBJS 84
Ross et al age 10 years old, 62 children 95% satisfaction -188 toes
Hamer et al. RCT JBJS 93b4 year follow upNo difference between flexor tenotomy and flexor transfer
Metatarso-phalangeal joint release (MTPJ)
Sequential staged release of MTPJ depending on the severity and correction of deformity through dorsal longitudinal incision
EDL & EDB ‘z’ lengthening Dorsal capsulotomy Collateral ligament release Reduction of Plantar plate Lesser MT osteotomy
Dhukaram et.al Hammer Toe Correction with extended metatarso phalangeal joint release JBJS[Br] 84-B Sep 2002 (986–90)
PIPJ Fusion Technique (similar to DIPJ Fusion)
Elliptical transverse or longitudinal incisionExtensor tendon and release collateral ligamentsResect head of PP and curette art. surface base of MPUse double ended 1.4/1.6mm k wire and predrill the PPRetrograde fixation from base of MP distally and drive k wire through predrilled PPCommon complications of PIPJ fusion include malunion, floating toe, residual pain, non-unionUpto 1/3rd could have fibrous union but only 1 to 2% symptomaticLehman reported 15% dissatisfaction in 100 feet
Lehman et. Al Treatment of Symptomatic hammertoe with PIPJ arthrodesis. Foot Ank Int. 16(9):535-541. 1995
Alternate Methods
PIPJ Excisional arthroplastySimilar to PIPJ fusion but EDL tendon interposed between PP & MP and sutured to distal slip in tensionNo k wire fixation Maintains mild PIPJ flexion rather straight
Alternate Fixation for PIPJ fusion
Stay Fuse implant
Smart toe implant
Weils Osteotomy
Indications: Metatarsalgia due to long lesser ray or short first ray, Unstable lesser MTPJ, Subluxed/ dislocated MTPJ including Rheumatoid footAim to shorten the lesser ray and restoration of metatarsal parabolaProximal sliding of MT head alone doesn’t result in elevation but metatarsalgia shifts proximally. It requires adding additional wedge
Weils
A Wedge is added to elevate MT head to reduce risk of metatarsalgia and floating toe
Fixation method – Twistoff screws
Barouk LS . Forefoot Reconstruction
Technique
Dorsal longitudinal incisionEDL & EDB ‘z’ lengtheningDorsal capsulotomyCollateral ligament releaseReduction of Plantar plate Osteotomy parallel to sole of feet with wedgeFixation with twistoff screwRemoval of dorsal lipMedio-lateral translation of MT head to correct corresponding lesser toe deformities
Complications:Stiffness due to arthrofibrosis MTPJ Floating toe – Oblique cut and proximal translation of MT head could move center of rotation of MTPJ plantar to intrinsics so intrinsics act as dorsiflexor of toe Metatarsalgia due to excessive plantar displacement of MT head or failed to restore parabola
Hofstaetter et al The weil osteotomy: A seven year follow-up. JBJS 87:1507-1511. 2005
BRT osteotomy
Isolated metatarsalgia due to depression of MT head but normal length (parabola)Aim to elevate the metatarsal headOsteotomy 60degrees to sole of feet, preserve plantar hingeFixation with 2.3mm Barouk or twistoff screw
Preserve plantar hinge
Forefoot reconstruction LS Barouk
Stainsby Procedure
Indication: Salvage procedure for dislocated MTPJ. The displaced plantar plate exerts plunger effect on MT head
Technique: Dorsal approachSubtotal phalangectomyReduce plantar plate and fatpad under metatarsal head and stabilise with K wireFlexor and extensor tendons are sutured together to provide additional stability
Briggs PJ, Stainsby GD. Metatarsal head preservation in forefoot arthroplasty. Foot Ankle Surg 2001; 7:93-101Hossain S et al. Stainsby procedure for non-rheumatoid claw toes. Foot Ankle Surg 2003; 9:113-8
Proximal subtotal phalangectomy
Reduction of plantar plate
Lesser Metatarsal head Resection
Hoffman Fowler procedure – Dorsal & Plantar incisions
Lesser Metatarsal head Resection
Clayton – Dorsal incision Kates
Lipscomb- Webspace incisions
Rheumatoid Foot Surgery
Coughlin JBJS Am 2000 Mann JBJS Am 1984
Ist MTPJ arthrodesis and lesser metatarsal head excision - 96% subjective - Excellent to good resultsMany studies reporting pan MTPJ resection – recognised to be associated with high recurrence rate
Bunionette
Type 1 – large, wide 5th metatarsal head Type 2 – lateral 5th metatarsal shaft bowing Type 3 – increased 4th/5th MT angle
Any combination of 1 -3 proposed by Koti & Mafulli
Coughlin
Combination of type II & III
Bunionette
Lateral incision
Scarf osteotomy for bunionette is gaining popularity
Fixation method – Twistoff screw/ Mini-fragment screw
Deformity
Surgical Options
Type I Shaving 5th MT head or Distal MT Osteotomy – Chevron/ Weil/ Oblique
Type II Distal MT osteotomy – Oblique or Midshaft oblique MT osteotomy
Type III Midshaft Oblique Osteotomy or Proximal Osteotomy
Coughlin
Guha et.al 'Reverse' scarf osteotomy for bunionette correction: Initial results of a new surgical technique. Foot Ankle Surg. 2012 Mar;18(1):50-4.
Mortons NeuromaNot a true neuroma but a degenerative lesion Common in 3rd webspace followed by 2nd & 4th Approach – Dorsal, Plantar (scar sensitivity)Divide inter-metatarsal ligament and bury the proximal stump to lower the risk of recurrenceAkermark :Similar outcome with dorsal and plantar incisions. Higher scar problems with plantar approach and missed neuroma with Dorsal approach
Akermark et. Al Plantar versus dorsal incision in the treatment of primary intermetatarsal Morton's neuroma. FAI 2008 Feb;29(2):136-41Nery et.al Plantar approach for excision of a Morton neuroma: a long-term follow-up study. JBJS A 2012 Apr 4;94(7):654-8.
Dorsal Webspace Appoach