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