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Forefoot Reconstruction

Forefoot Reconstruction. Michael Lapner 2009 04 15. Sections. Hallux Valgus Hallus Varus Hallux Rigidus Lesser Toe Deformities Intractable plantar Keratosis Freiberg Infraction Bunionette. Hallux Valgus. Etiology & Pathoanatomy. Etiology. Cause debated multifactorial

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Forefoot Reconstruction

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  1. Forefoot Reconstruction • Michael Lapner • 2009 04 15

  2. Sections • Hallux Valgus • Hallus Varus • Hallux Rigidus • Lesser Toe Deformities • Intractable plantar Keratosis • Freiberg Infraction • Bunionette

  3. Hallux Valgus • Etiology & Pathoanatomy

  4. Etiology • Cause • debated • multifactorial • reactive ground forces/dynamic muscular • repetitive valgus force with wt bearing

  5. med cap attenuated sesamoid ridge worn sesamoid displaced lateral structures contract

  6. Extrinsic Factors • Ill fitting shoes • narrow box • women higher prevalence

  7. Intrinsic factors • genetic • hypermobility first TMT joint • increase IMA 1-2 (or increased pes planus) • pes planus • shape of first metatarsal head

  8. Clinical Presentation • Pain • difficulty with footwear • skin irritation • ulceration infection • Occupation/sports/footwear/activity level

  9. Physical Exam • Inspection • standing • callosities • palpation • tenderness (medial eminence / under 2nd MT head)

  10. Physical Exam • ROM • foot/ankle • motion of first MTP • motion of first TMT/compare to other side • sagittal / transverse plane • passive ROM of 1st MTP with manual correction of hallux valgus

  11. Physical Exam • Vascular/Neurologic exam documented • appropriate consultation as required • may consider non-operative treatment

  12. Radiographic Exam • wt bear AP • lateral • non-wt/bearing oblique • special sesamoid view (axial forefoot)

  13. Radiographic assessment • AP • HVA • IMA 1-2 measured • DMAA

  14. Radiographs • HVA • normal < 15 • IMA 1-2 • normal < 9 • MPV • DMAA • normal < 10

  15. Classification

  16. Radiographs • Prox/Distal Phalanx angle measured • hallux valgus interphalangeus • review location sesamoids • congruency • size of medial eminence • arthritis

  17. Non Surgical Treatment • Education • wide footwear • sketch foot size • soft shoes • bunion press to relieve pressure • padding • orthoses unlikely to be of much benefit

  18. Surgical Rx • Indication • failed non-op • pain/limited activities/inability to wear footwear • not cosmesis • expectations discussed

  19. Principles - HV • maintain/obtain congruent joint • mild deformity - distal osteotomy • mod/severe deformity - prox osteotomy • arthrodesis/combined osteotomies

  20. HV Mild Rx • Mild deformity • distal chevron osteotomy • Mod/severe with incongruent joint • distal soft-tissue procedure + prox osteotomy • Severe • arthrodesis • Keller (resection arthroplasty) - low function

  21. Distal Correction • Modified McBride • medial capsulotomy with imbrication • excision of medial prominence • release of contracted deforming structures • adductor/lat capsule/transverse MT ligament

  22. Distal Correction • distal chevron • V-shape osteotomy of MT head • capital fragment 4-6 mm translate laterally • medial joint capsule plicated • required congruent joint • no increased risk of osteonecrosis w/ lat release

  23. Distal Correction • Biplanar chevron may be added • medial close wedge

  24. Proximal Correction • soft tissue • correct congruency • bony • osteotomy to correct MVA/IMA12

  25. Options-proximal • Proximal crescentic • proximal chevron • scarf • lateral close wedge • medial opening wedge

  26. Images

  27. Images

  28. Considerations • shortening • dorsiflexion • complications • recurrence • varus • non-union

  29. Biomechanics • Proximal chevron/long oblique/crescentic • superior fixation with screws vs K-wires

  30. Post-Op • compressive dressing • wt bear in post-op stiff shoe • until radiographic union (8 weeks)

  31. Arthrodesis • Dorsal incision • bony cuts made • lag screw/plate may be used (bone quality) • walk boot (12 weeks)

  32. Hallux Valgus Interphalangeus • medial close wedge base of prox phalanx • screw/wire/staple • called Akin osteotomy

  33. Other procedures • Cotton • medial open wedge of first cuneiform • IMA12 • Reverdin • medial distal close wedge of first MT

  34. Lesser Toe Deformities • deformities of 2nd-5th toes • trauma • inflammatory • neurologic • ill-fit shoewear • congenital

  35. Lesser Toes • Lesser toes • balance/pressure distribution • passive & active stabilizers

  36. Passive stabilizers • plantar aponeurosis • capsule • plantar plate • collaterals

  37. Active stabilizers • extrinsic muscles • EDL/FDL • intrinsic muscles • FDB EDB IO L • tibial nerve extrinsic & intrinsic • peroneal extrinsic only

  38. Anatomy • EDL & EDB extend MTP (extensor hood) • EDL central slip into middle phalanx • medial/lateral slip insert to distal phalanx

  39. Anatomy • EDL/EDB extend MTP PIP DIP • FDL (deep FDB) inserts at distal phalanx • strong DIP flex • weaker PIP/MTP flexors • FDB bifurcation - inserts mid phalanx

  40. Anatomy • Lumbricals/interossei • plantar to axis of motion of MTP • flex MTP • extend PIP/DIP (dorsal extensor hood)

  41. Terminology

  42. Clinical Presentation • symptoms with closed-toe shoes • calluses/blisters • pain under MT head • position of toes observed with wt bearing • deformity of 1st ray • flexibility • radiographs obtained

  43. Non Surgical Treatment • Deep toe box • proper fit shoes • slings • pads • taping devices • manual stretching (no evidence)

  44. Surgery • Failure of conservative measures • pain • inability to comply with shoe wear restrictions

  45. Surgical Treatment • various soft-tissue and bony procedures

  46. Complications • discussed pre-op • recurrence • incomplete correction • vascular compromise • clear communication with patient • short toes/stiff joint/prolonged swelling

  47. Mallet Toe • Flexible • percutaneous flexor tenotomy • at DIP crease • Rigid • bony correction - resection arthroplasty • DIP arthrodesis +/- FDL tenotomy • k-wire (4-6 weeks)

  48. Mallet

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