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Session III

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.

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Session III

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  1. Session III Lesser rays Mr. V. Dhukaram

  2. 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

  3. 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

  4. Lesser Toe Deformities

  5. Mallet toe • DIPJ Fusion technique -Transverse or longitudinal incision • Extensor tendon and release collateral ligaments • Resect head of MP and curette base of DP articular surface • Retrograde 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 fusion Flexible – FDL tenotomy Coughlin Operative repair of the mallet toe. FAI 16(3):109-116. 1995

  6. Summary of Surgical treatment of Hammer toes & Claw toes Claw toes will require additional DIPJ fusion/ tenotomy / FDL transfer depending on its flexibility

  7. Girdlestone -Taylor (FDL transfer) FDL to takeover the function of Intrinsics to maintain MTPJ in neutral

  8. Flexor tenotomy Vs FDL transfer Flexor tenotomy JBJS 84 • Ross et al age 10 years old, 62 children • 95% satisfaction -188 toes Hamer et al. RCT JBJS 93b • 4 year follow up • No difference between flexor tenotomy and flexor transfer

  9. 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)

  10. PIPJ Fusion Technique (similar to DIPJ Fusion) • Elliptical transverse or longitudinal incision • Extensor tendon and release collateral ligaments • Resect head of PP and curette art. surface base of MP • Use double ended 1.4/1.6mm k wire and predrill the PP • Retrograde fixation from base of MP distally and drive k wire through predrilled PP • Common complications of PIPJ fusion include malunion, floating toe, residual pain, non-union • Upto 1/3rd could have fibrous union but only 1 to 2% symptomatic • Lehman reported 15% dissatisfaction in 100 feet Lehman et. Al Treatment of Symptomatic hammertoe with PIPJ arthrodesis. Foot Ank Int. 16(9):535-541. 1995

  11. Alternate Methods • PIPJ Excisional arthroplasty • Similar to PIPJ fusion but EDL tendon interposed between PP & MP and sutured to distal slip in tension • No k wire fixation • Maintains mild PIPJ flexion rather straight • Alternate Fixation for PIPJ fusion Stay Fuse implant Smart toe implant

  12. Weils Osteotomy • Indications: Metatarsalgia due to long lesser ray or short first ray, Unstable lesser MTPJ, Subluxed/ dislocated MTPJ including Rheumatoid foot • Aim to shorten the lesser ray and restoration of metatarsal parabola • Proximal sliding of MT head alone doesn’t result in elevation but metatarsalgia shifts proximally. It requires adding additional wedge

  13. 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

  14. Technique • Dorsal longitudinal incision • EDL & EDB ‘z’ lengthening • Dorsal capsulotomy • Collateral ligament release • Reduction of Plantar plate • Osteotomy parallel to sole of feet with wedge • Fixation with twistoff screw • Removal of dorsal lip • Medio-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

  15. BRT osteotomy • Isolated metatarsalgia due to depression of MT head but normal length (parabola) • Aim to elevate the metatarsal head • Osteotomy 60degrees to sole of feet, preserve plantar hinge • Fixation with 2.3mm Barouk or twistoff screw Preserve plantar hinge Forefoot reconstruction LS Barouk

  16. Stainsby Procedure Proximal subtotal phalangectomy • Indication: Salvage procedure for dislocated MTPJ. The displaced plantar plate exerts plunger effect on MT head • Technique: Dorsal approach Subtotal phalangectomy Reduce plantar plate and fatpad under metatarsal head and stabilise with K wire Flexor and extensor tendons are sutured together to provide additional stability Reduction of plantar plate Briggs PJ, Stainsby GD. Metatarsal head preservation in forefoot arthroplasty. Foot Ankle Surg 2001; 7:93-101 Hossain S et al. Stainsby procedure for non-rheumatoid claw toes. Foot Ankle Surg 2003; 9:113-8

  17. Lesser Metatarsal head Resection • Hoffman Fowler procedure – Dorsal & Plantar incisions

  18. Lesser Metatarsal head Resection Clayton – Dorsal incision Kates Lipscomb- Webspace incisions

  19. Rheumatoid Foot Surgery Coughlin JBJS Am 2000 Mann JBJS Am 1984 Ist MTPJ arthrodesis and lesser metatarsal head excision - 96% subjective - Excellent to good results Many studies reporting pan MTPJ resection – recognised to be associated with high recurrence rate

  20. Bunionette Coughlin • 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 Combination of type II & III

  21. Bunionette • Lateral incision • Scarf osteotomy for bunionette is gaining popularity • Fixation method – Twistoff screw/ Mini-fragment screw 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.

  22. Mortons Neuroma • Not a true neuroma but a degenerative lesion • Common in 3rdwebspace followed by 2nd & 4th • Approach – Dorsal, Plantar (scar sensitivity) • Divide inter-metatarsal ligament and bury the proximal stump to lower the risk of recurrence • Akermark :Similar outcome with dorsal and plantar incisions. Higher scar problems with plantar approach and missed neuroma with Dorsal approach Dorsal Webspace Appoach Akermark et. Al Plantar versus dorsal incision in the treatment of primary intermetatarsal Morton's neuroma. FAI 2008 Feb;29(2):136-41 Nery 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.

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