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6.

2 Digital Surgery

Keith Springer, DPM


The function of digits are: Stabilization Balance Kinesthetics Deceleration

Anatomy of the Digits


Bone

Metatarsal head-is covered with articular cartilage distally and articulates with the base of the proximal phalanx. The articular surface extends more proximal on the plantar surface then the dorsal surface. Plantarly there are two condyles, which are separated by a notch where the flexor digitorum longus tendon lies. Proximal to the edge of the articular cartilage is a groove, which is where the capsule attaches. Posterior to the groove are two tubercles, dorsomedial and dorsolateral. These grooves are the attachments of the medial and lateral collateral ligaments and the medial and lateral metatarsoglenoid suspensory ligaments. Proximal phalanx-At the base and just distal to the articular cartilage is a groove for the insertion of the capsule. On the plantar medial and plantar lateral aspects at each base there are tubercles for the attachments of the collateral ligaments. The medial tubercle on the second toe receives the insertion of the first dorsal interossei and the medial tubercle of three, four, five, the insertion of the plantar interossei. The lateral tubercle of two, three, four receives the insertion of the two, three, four dorsal interossei and the fifth the insertion of the abductor digiti minimi and the flexor digiti minimi. Just distal to the cartilage plantarly is the attachment of the plantar metatarsophalangeal ligament. The shaft is convex dorsally and flat inferiorly. The head has articular cartilage, which extends more proximally plantarly and has a groove for the passage of the flexor tendons. Plantarmedial and plantarlateral are tuberosities for the origin of the collateral ligaments and just proximal to the articular surface marks the attachment of a very thin capsule. Middle phalanx-base has articular cartilage. There is a dorsomedial and dorso lateral tubercle for the insertion of the collateral ligament and just distal to the articular surface marks the attachment of the capsule. The plantar ligament attaches just distal to the articular cartilage. The middle slip of the extensor tendon inserts dorsally at its base. The flexor digitorum brevis inserts on the medial and lateral sides at the base. At the head just proximal to the articular cartilage is the origin of the very thin capsule and there are plantar medial and plantar lateral tubercles for the origin of the collateral ligaments. Distal phalanx-triangular in shape. An articular surface is present only at the base with the insertion of the capsule just distal to this surface and two small tubercles for the insertion of the collateral ligaments. At the base dorsally 2 slips of the extensor tendon inserts and plantarly at the base two slips of the FDL inserts.

Arthrology

Metatarsophalangeal joint-A discrete synovial joint. The capsule attaches more proximal plantarly then dorsally. The capsule is much thinner dorsally and is reinforced by the EDL and the extensor expansion. It is thicker medially and laterally and reinforced by the collateral ligaments. It is attached loosely both dorsally and plantarly to allow for motion.

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The collateral ligaments are triangular in shape and blend with the capsule. They restrict transverse plane
motion. They run from the dorsomedial/dorsolateral tubercle on the metatarsal to the plantarmedial/plantarlateral tubercle on the proximal phalanx. The suspensory metatarsophalangeal ligament runs from the tubercles on the metatarsal heads into the plantar pad. Along with the collateral ligament they appear as two distinct bands 68% of the time or as one triangular band 32% of the time. The plantar MPJ ligament (Glenoid ligament) reinforces and blends with the capsule. It strengthens the joint plantarly. It is partially fibrocartilagenous and flexor plate, volar plate, plantar capsule forms the plantar pad or plate. This pad is tightly attached to the proximal phalanx and loosely attached to the metatarsal allowing the proximal phalanx to move. Medially and laterally the pad is attached to the deep transverse metatarsal ligament. There is a groove in the pad plantarly for the passage of the flexor tendons. The motion is primarily sagittal with 50-60 of dorsiflexion and 30-40 plantarflexion. The plantar pad moves with MPJ motion. PIPJ & DIPJ- both are synovial joints(ginglymus or hinge). The motion is in the sagittal plane with more plantarflexion then dorsiflexion. There is more motion at the PIPJ then the DIPJ. Both have a capsule and collateral ligaments that are tighter then at the MPJ. Both joints have a strong fibrous ligament plantarly similar to the MPJ. Sometimes sesamoids are found at these IPJs (mostly seen at the PIPJ of two and three).

Muscle

Extensor Digitorum Longus-four slips that insert into the middle and distal phalanges. Function is to extend the four lesser toes, extend the ankle, a weak evertor and oppose the FDL. Flexor Digitorum Longus-divides into four slips at the navicula where it receives the quadratus plantae insertions and then gives rise to the lumbricle origins medially. They run in a sheath with the FDB at the metatarsal heads created by the plantar aponeurosis. They insert plantarly into the base of the distal phalanx. They plantarflex the MPJ, PIPJ, DIPJ and ankle and they are the antagonist of the EDL. Extensor Digitorum Brevis-origin is the dorsolateral aspect of the calcaneus just anterior to the sinus tarsi. Runs distally and divides into 4 with the first tendon being the EHB. There is NO EDB tendon to the fifth toe. Slips two, three, four insert into the lateral aspect of the EDL just distal to the MPJ. The EDL & EDB form a trifurcate system with the central portion inserting into the middle phalanx and the two outer slips into the distal phalanx. The lateral slip of this trifurcate is often considered the EDB. (Fig. 1)

Figure 1.

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Flexor Digitorum Brevis-origin is the medial calcaneal process. Divides into four slips and runs superficial
or plantar to the FDL. At the base of the proximal phalanx the tendon splits and allows the FDL to pass through. At this level it is now dorsal to the FDL. The split unites and then inserts into the base of the middle phalanx on both sides. Its function is to PF both the MPJs & PIPJs of toes two, three, four, five. (Fig. 2)

Figure 2.

Quadratus plantae-flexor digitorum accessorius-origin is the medial and lateral plantar calcaneus and inserts
into the FDL tendon laterally. It aids in the posterior pull of the FDL (see below). Lumbricles-origin is the medial aspect of the FDL runs distal and medial and passes deep or plantar to the deep transverse metatarsal ligament and inserts into the medial aspect of the extensor expansion. Its function is to plantarflex the MPJ and dorsiflex the IPJ. Plantar interossei-there are three. The origin is the medial aspect of the three, four, five metatarsal move distally and is dorsal to the deep transverse metatarsal ligament and insert into the medial tubercle of the proximal phalanx the capsule and extensor expansion of the three, four, five toes. They adduct these three toes. Dorsal interossei-There are four that arise form the adjacent sides of the metatarsals run distal and dorsal to the deep transverse metatarsal ligament and insert into the tubercle of the base of the proximal phalanges and the extensor expansion of toes two, three, four. The first dorsal interossei inserts into the medial two toe the two, three, four dorsal interossei into the lateral aspect of toes two, three, four. Abductor digiti minimi-lateral process of the calcaneus to the lateral plantar aspect of the proximal phalanx of the 5th. It abducts and aids in plantarflexion Flexor digiti minimi brevis-medial plantar base of the fifth metatarsal to the plantar lateral aspect of the base of the proximal phalanx. Plantarflexes and abducts the fifth toe.

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Extensor Expansion

Figure 3. Extensor Expansion

A fibroaponeuritic structure that anchors the EDL and EDB. It extends from the MPJ to the PIPJ. This fibroaponeuritic structure extends around the medial and lateral aspect of the proximal phalanx and attaches plantarly into the plantar plate, MPJ capsule, flexor tendon sheath and suspensory ligament. It does not attach directly to bone. The fifth is the least developed. The two, three, four, and five differ from the hallux. Proximally the fibers are oriented transversely and is called the extensor sling and distally the fibers are oriented obliquely (from posterior inferior to anterior superior) and are called the extensor wing or extensor hood. The lumbricles form the oblique border of the extensor wing medially and inserts into the central and medial slip of the extensors. The lumbricles PF the MPJ and DF the IPJ. This occurs because the lumbricle when it fires tightens the wing distally causing dorsiflexion of the PIPJ and slackens the sling proximally to yield to plantarflexion of the MPJ by the flexors. This action is maintained by the lumbricles because they are plantar to the deep transverse metatarsal ligament. The dorsal and plantar interossei are dorsal to the deep transverse metatarsal ligament and are parallel to the metatarsal bone axis. They insert primarily into the base of the proximal phalanx and minimally into the extensor expansion. If they are in proper alignment they stabilize the MPJ. They do not plantarflex it. The function of the extensor expansion is to keep the digit in a rectus position. When the extensors fire they tend to dorsiflex the MPJ creating a tightening on the extensor sling and a slackening of the extensor wing. This would create dorsiflexion of the MPJ and plantarflexion of the IPJ creating a hammertoe. The lumbricles when in proper position fire and they tighten the extensor wing and slacken the extensor sling thus placing both joints into a rectus position.

Plantar Plate
Occurs at the MPJs & PIPJs and provides for a cushion for weight bearing forces. They are the most important stabilizers of the MPJ. They have a strong attachment into the base of the proximal phalanx and a loose one into the metatarsal head.

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Plantar plate dysfunction-occurs due to toe off stress, chronic hyperextension, rupture with subluxation, and
dislocation. All this leads to hammertoes.

Etiology of Digital Deformities


Congenital Heredity Shoes-heel height Trauma Relative length of toes Hallux Valgus Arthritities and connective tissue diseases Neuromuscular diseases Biomechanical

Biomechanical etiology

Flexor Stabilization-most common being seen about 90% of the time. It is the result of the flexors gaining a
mechanical advantage over the intrinsics mostly the interossei. If we do a gait analysis, you see an increase in the deformity primarily in mid-stance. Extensor substitution-seen about 10% of the time. It occurs as a result of the anterior muscles gaining a mechanical advantage over the intrinsics specifically the lumbricles. If we do a gait analysis, you see an increase in the deformity primarily during swing phase. Flexor substitution-least common etiology. Usually due to a weak triceps surae muscle. All of the posterior muscles including the FDL must now overwork to plantarflex the ankle. The FDL aids in plantarflexing the ankle and thus causes the toes to grasp the ground and eventually lead to hammer toes. We see an increase in the digital deformity during the propulsive phase of gait. It is important when evaluating digital deformities to do a gait analysis. This will provide the doctor with the biomechanical etiology. This in turn will aid in selecting the proper surgical treatment.

Classification of Digital Deformities Mallet toe-a one-joint deformity that involves plantarflexion of the distal interphalangeal joint. Hammertoe-a two-joint deformity that involves dorsiflexion of the metatarsophalangeal joint and plantarflexion of the proximal interphalangeal joint. The distal interphalangeal joint is in neutral. Claw toe-a three joint deformity that involves dorsiflexion of the metatarsophalangeal joint and plantaflexion of both the proximal and distal interphalangeal joints. 5th toes - rare to see a true hammering or claw toe. Usually one sees an adductovarus deformity with a keratotic lesion overlying the PIPJ. The etiology is due to an imbalance in the posterior vector pull between the flexor digitorum longus and quadratus plantae muscle (Fig. 4). Seen mostly commonly due to excessive pronation and seen in flexor stabilization.

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Figure 4.

Hammered hallux-dorsiflexion of the 1st metatarsophalangeal joint and plantarflexion of the interphalangeal joint. The etiology can be swing or stance phase but it is most commonly due to an iatrogenic cause. Hallux malleus-plantarflexion on the interphalangeal joint. Mostly due to an iatrogenic cause.
Flexibility of Digital Deformities
It is important to know whether you have digital deformities that are completely flexible, semi-flexible (semirigid) or rigid. Please note that the terms semi-flexible and semi-rigid can be used interchangeably. The flexibility of the deformity influences the surgical procedure to be performed. If the deformity is totally flexible one thinks towards doing soft tissue procedures. With any form of rigidity one thinks of performing osseous procedures.

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Kellikian Push Up Test (Fig 5.)

Figure 5.

The examiner loads the fore foot and observes what happens to the metatarsophalangeal joints. It is important to note that this is a test to see the flexibility of the MPJs only. The flexibility of the interphalangeal joints is tested manually only Flexible-a joint that completely and totally reduces Semi-flexible or semi-rigid-a joint that can only be partially reducible Rigid-a joint that does not reduce at all

Surgical Management of Digital Deformities


Before selecting a surgical procedure one must first determine: Which deformity do we have Mallet toe Hammer toe Claw toe Etiology Flexor stabilization Extensor substitution Flexor substitution Flexibility Flexible Semi-flexible/semi-rigid Rigid

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Osseous Management of Digital Deformities Arthroplasty-creation of a new joint (PIPJ &/or DIPJ) Arthrodesis-fusion of PIPJ &/or DIPJ
Post arthroplasty-resection of the head of the proximal phalanx for a hammertoe that is semi-flexible (semirigid), rigid with a flexor stabilization etiology. An arthroplasty of both the PIPJ & DIPJ can be done for a semi-flexible (semi-rigid) claw toe with a flexor stabilization etiology. An arthroplasty of the DIPJ only is done for semi-flexible (semi-rigid) and rigid mallet toes. Of the numerous surgeries that are described, the most universally performed procedure for a hammer toe has been the Post arthroplasty. While it does little to restore the intrinsic muscle stabilization it does reduce the deformity and symptomotogy and it has withstood the test of time.

Arthroplasty for Hammer toes


Skin Approaches Can Be: Dorsal linear Two longitudinal semi-elliptical Two transverse semi-elliptical incisions Medial or lateral linear incision Tendon Approaches: Transverse at the level of the PIPJ Linear through the tendon and retract medially and laterally Cut the extensor expansion and reflect the tendon either medially or laterally Collateral Ligament Both medial and lateral collateral ligaments should be severed Bone The head should be removed just as the bone begins to flare One can use: Double action bone cutter Rongeur Saw (oscillating, reciprocating etc) Giglie saw Osteotome and mallet Closure Tendon re-approximated with absorbable suture Skin closed with absorbable or non-absorbable suture

Arthroplasty for a Mallet Toe


Arthroplasty for a mallet toe is exactly the same as that for a hammer toe except the bone is removed from the head of the middle phalanx. Arthroplasty for a claw toe-a combination of the procedure for a hammer plus a mallet toe. The incisions can be straight linear, a T-shaped incision or two transverse incisions at the level of the joints

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Arthroplasty for fifth toes


The arthroplasty procedure for fifth toes is exactly the same as is done for hammer toes two, three, and four. Plus, a lateral middle hemi-phalangectomy is performed. This is done because most patients complain of the keratotic lesion that overlies the PIPJ and therefore part of the middle phalanx. In most cases if a lateral middle hemiphalangectomy is not done only a portion of the keratotic lesion will disappear. To determine if enough of the middle phalanx has been removed one should palpate the remaining middle phalanx where the keratotic lesion is. If one feels a depression then enough bone has been removed. If one presses and feels hard bone below then not enough bone has been removed and more should be taken. When evaluating a fifth toe is also important to inspect the lateral border of the fifth toenail. If there is a keratotic lesion or a thickening of the skin in that area, then at the time of surgery the keratotic skin and the underlying bone should be removed.

Digital Fusions
Indications
Flexor substitution Extensor substitution Progressive neurological deformities Failed arthroplasty Flail toe Transverse IPJ deformity

Fusion Techniques
End to end arthrodesis-resection of the cartilage on each end of the joint down to subcondral bone. The joint is then stabilized with a Kirschner wire, stainless steel wire, staple, screw, absorbable pin Peg-in-hoe arthrodesis-the head of the bone is denuded of its articular cartilage and then made into a peg (pencil point) that is then inserted into a hole in the base. Any of the various fixation devices discussed in the end-to end arthrodesis are then performed V arthrodesis-creating a V within the joint and then maintaining this position with any of the fixation devices Fusions of the appropriate joint(s) depends on whether you have a hammert oe, claw toe or mallet toe. Lambrinudi procedure-fusion of the PIPJ & DIPJ for a claw toe. Diaphasectomy-performed when there is a very long proximal phalanx. It is the removal of a portion of the proximal phalanx. Not done often because the healing time is much longer then an arthroplasty. Resection of the base of the proximal phalanx (mini-Keller) for toes 2, 3, 4, 5 should be avoided. It destabilizes the MP joints and creates flail toes

Soft Tissue Surgery for Digital Deformities


General Indications
Flexible deformity Adjunct to osseous procedures When performing digital surgery it is imperative to evaluate and treat the MPJ deformity

Soft Tissue Surgeries


Tenotomy-cutting of a tendon Tenectomy-cutting of a tendon but taking a section of the tendon out Extensor hood release-cutting the extensor expansion medially and laterally from the MPJ to the PIPJ

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Capsulotomy-cutting the MPJ capsule Tendon lengthening Tendon transfer Skin plasty Skin incisions - done mostly for fifth toes to aid in its derotation - it is a teardrop incision (semi-elliptical) that runs from distal medial to proximal lateral. Extensor tenotomy - reduces MPJ contractures Extensor hood Release - reduces MPJ contractures Extensor lengthening - reduces MPJ contractures Flexor tenotomy - reduces IPJ contractures Capsulotomies - reduces MPJ contractures Cutting of the collateral ligament and freeing the plantar plate at the MPJ - reduces MPJ contractures Flexor tendon transfers-done with flexible deformities and reduces both the PIPJ & MPJ contractures. It is the transfer of the FDL or FDB to the proximal phalanx. This reduces the IPJ deformity. When the flexor fires it reduces the MPJ deformity. Most of the soft tissue procedures that are performed are used to reduce the MPJ deformity. There are only two soft tissue procedures written in the literature that are used by themselves to reduce completely flexible deformities. One is a flexor tenotomy for a completely flexible mallet toe. The other is a flexor tendon transfer for a completely reducible claw or hammertoe

Sequential Reduction of Hammer toes


Head resection Load the foot and see what happens to the MPJ- if it reduces completely then you are done if it does not then Extensor hood release/extensor tendon lengthening Load the foot and see MPJ capsulotomy (this may include collateral ligament release and plantar plate release) Load the foot and see Tendon transfer Load the foot and see Arthrodesis of IPJs If the MPJs do not reduce after performing the sequential reduction then you have a rigid MPJ, which should be attacked by: Metatarsal head resection Shortening metatarsal osteotomy

Miscellaneous Digital Deformities


Helloma Molle
Helloma Molle is a soft corn mostly found in the fourth interspace. It is not any corn that is found interdigitally. If is only those macerated corns. Etiology Rubbing of the head of the proximal phalanx of the fifth toe against the lateral base of the proximal phalanx of the fourth toe (Fig. 6).

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Figure 6.

Treatment Arthroplasty fifth toe Condylectomy fourth toe Arthroplasty fifth toe with condylectomy of the fourth toe Syndactyly - performed when prior procedures have failed, when there is a chronic draining ulcer, or the fifth toe is flail

Clinodactyly - Deviated Toe


Clinodactyly is a transverse plane deformity at the PIPJ &/or DIPJ. The treatment for this deformity is either an arthroplasty or arthrodesis at the affected joint(s). Arthrodesis seem to give better results.

Helloma Durum
Helloma durum is a hard corn found along the medial or lateral aspects of the digits usually at the level of one of the IPJs. Usually due to a hypertrophy of the bone at the level of the heloma durum. Treatment Excision of the hypertrophied bone using a burr, rasp, or rongeur.

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Second MTPJ Instability

Definition: It is the imbalance of the functioning of both the intrinsic and extrinsic musculature, which eventually leads to MTPJ & IPJ deformities.

Synonyms:

Cross Over Second Toe Deformity Second MTPJ Dysfunction Second MTPJ Stress Syndrome Pre-dislocation Syndrome Hammer Digit Syndrome

Etiology:

Chronic synovitis/chronic capsulitis 2nd MTPJ Chronic MTPJ hyperextension - high heeled shoes Long 2nd metatarsal Hallux Valgus Hallux Interphalangeus Chronic repetitive microtrauma to plantar plate

Pathology:

Plantar plate attenuation or rupture Lateral capsule/ligament attenuation or rupture Rupture of first dorsal interossei tendon Distal fat pad displacement Keratotic lesions submetatarsal 2, PIPJ &/or DIPJ Dorsal elevation/dislocation Medial deviation Tenderness dorsally & plantarly MTPJ Edema dorsally & plantarly MTPJ Lachman Test (Toe translation test, Dorsal draw test) Toe held in 20-25 degrees dorsiflexion Vertical translation of proximal phalanx Positive test is two or more millimeters Lachman Test Stages Stage 0 no dorsal translation of proximal phalanx Stage 1 subluxed but not dislocated Stage 2 phalangeal base can dislocate but is manually reduced Stage 3 phalangeal base is fixed in dislocated position X-rays Metatarsal length Metatarsal morphology-large lateral condyle Presence of Hallux Valgus and/or Hallux Interphalangeus Transverse or sagittal plane deformities Arthrogram Extravasation of dye into flexor sheath Plantar plate tear MRI Focal increase signal in torn plantar plate

Clincal Exam:

Clinical Tests:

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Surgical Planning:

Presence of hallux valgus Presence of hallux interphalangeus Flexibility/rigidity of second MTPJ Transverse plane deformity of 2nd toe Degree of instability of second MTPJ Hallux Valgus/Interphalangeus repair Digital arthroplasty/arthrodesis Sequential MTPJ reduction Plantar plate release Primary repair of plantar plate Long or short flexor tendon transfer Intrinsic (interosseous) tendon transfer Decompression osteotomy 2nd metatarsal Translational osteotomy 2nd metatarsal second MTPJ arthroplasty K wire stability

Surgical Procedures:

Durlachers Corn
Durlachers corn is a hyperkeratotic lesion found along the lateral aspect of the fifth toenail. Often seen with PIPJ lesions of fifth toes but can be seen by itself. Treatment If seen with PIPJ keratotic lesion perform an arthroplasty with lateral middle and lateral distal hemiphalangectomies. If seen by itself the skin lesion should be ellipsed out with two semi-elliptical longitudinal incisions and then the bone removed with a burr, rongeur or rasp. Overlapping Fifth Toes Also known as: Digiti Quinti Varus Digiti Minimi Varus Appearance MPJ is dorsiflexed Toe is adducted Toe is in varus Historical procedures Ruiz-Mora - large plantar elliptical skin wedge with excision of the entire proximal phalanx. Butler - two racket shaped incisions completely encircling the toe and then an entire soft tissue release of the extensor tendons and the fifth MPJ Most of the time one sees these deformities in young children. They are usually not painful. The problem is that they are embarrassed to take their shoes off especially when they are swimming or go to physical education in school. The deformity as this time is usually flexible.

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The procedure of choice for a flexible overlapping fifth toe is: V to Y skin plasty EDL tenotomy Complete fifth MPJ capsulotomy Ruiz Mora plantar elliptical skin wedge If one sees an overlapping fifth toe in an adult the deformity will probably not be flexible. If that is so then the fifth MPJ may have to be reduced by either a fifth metatarsal head resection or a shortening fifth metatarsal osteotomy along with the V to Y skin plasty, the EDL tenotomy, and MPJ capsulotomy.

Hammered Hallux

Arthroplasty-should not be done because it de-stabilizes the joint and on propulsion will cause the distal tip of the toe to cock up. Arthrodesis-procedure of choice can be performed end to end peg and hole Fixation can be crossing K wires parallel K wires screws The EHL tendon is then brought proximally and placed into the capsule around the first metatarsal head (Modified Jones suspension)
Pinch Callus
Pinch Callus is caused due to excessive pronation. Occurs at the plantar-medial aspect of the hallux at the IPJ. Best treated with orthotics. If surgical intervention is decided then a medial approach is made and the plantar medial aspect of the IPJ is removed using a rongeur, burr, osteotome and mallet, bone cutter, rasp.

Treatment

IP Hallucal Sesamoid
IP Hallucal Sesamoid is seen in the plantar aspect of the hallux. The patient usually is complaining of a keratoma plantarly at the IPJ. A lateral x-ray will reveal an accessory sesamoid at the level of the IPJ. A DP view will reveal a radiodensity at the level of the IPJ. This sesamoid is found intracapsular. It is not found within the FDL tendon. There is some literature that says that there is a small slip of tendon in which the bone is encompassed thus making it a true sesamoid bone. The bone does sit more toward the lateral aspect of the IPJ. Treatment The surgical treatment is excision. There are four approaches: Plantar-easiest but for an unknown reason seed corns appear in the scar Lateral-gives best cosmetic result but technically difficult due to the second toe Medial is the most commonly done Dorsal-must open the IPJ to find bone. Too much dissection. Even though the sesamoid bone is not in the FDL and is in the capsule, the FDL is close and one must take care not to sever it

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Complications of Digital Surgery


Chronic Edema
Occurs usually due to: Lymphatic destruction Venous destruction Unequal digital length Treatment Elevation Compressive dressing Tube foam Tape Coban-Coflex

Angulational Deformities
Angulational Deformities results in loss of stability on one or all planes. The transverse plane is most commonly seen on the second toe. Etiology Adjacent digital deformity Poor dressing Treatment Take care not to place toes in a transverse plane position by placing dressing in between the toes. Use K wires intra-operatively to keep toes straight. If big toe abuts up against the second toe pre-op then perform proper osteotomy to correct hallux deformity For second toes if the hallux is abutting may want to fuse the second regardless of the etiology

Sagittal Plane Deformity-Recurrence


Etiology Inappropriate soft tissue procedure Inappropriate bony procedure Scar contraction Attacking the wrong joint Anterior fat pad migration Improper immobilization Wrong procedure (i.e. soft tissue for a rigid deformity) Treatment Proper preoperative evaluation

Frontal Plane deformity


Combination of sagittal and transverse deformities Treatment Proper pre-operative evaluation Attacking the proper joint Performing the proper procedure Guide postoperative scarring

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Transfer Lesions
Relative toe length - an excessively short toe can cause the adjacent long toe to be jammed in a shoe causing hammering Doing a solo extensor tenotomy - Since the extensor tendon is one that divides into four, if one is cut it increases the power of pull on the adjacent toe and may cause them to hammer. Doing one joint when the adjacent joint is in early disorder Doing one toe when the adjacent toe is already hammered but not as severe

Floating Toe Syndrome


The toe does not purchase the ground Etiology Anterior migration of the fat pad Metatarsal osteotomy Control Avoid a strict rectus toe Allow the toe to mold to the foot

Flail Toe/Telescoping Toe


Flail toe is a condition in which there is no control. The toe is completely functionless. A functional problem more then cosmetic. Telescoping toe-an extremely small toe. A cosmetic problem more then functional. Etiology for Both Excessive bone removal Overzealous deep tissue dissection Treatment Proper bony removal Proper soft tissue dissection Syndactyly Digital implant

Ischema
Ischema is caused by venous insufficiency or arterial insufficiency. Protocol for Treatment of Postoperative Blue Toe Syndrome Dependency Warm saline soaks Loosen dressing Heat to lower back Sympathetic block Loosen sutures Remove K wire (if used) Vasodilators Reverse epinephrin (if used)

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Numbness
Etiology Severance of nerve twigs-will see slow return Severance of digital nerve-will not see a return The burning sensation is usually regeneration of nerve in a trapped scar.

Infection Residual pain


Residual pain is most often due to scar tissue.

Excessive Shortening Regeneration of Bone Pseudarthrosis Rigidity Nail changes

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