Analysis of anatomic variations in cleft hands

PURPOSE: This study presents an overview of the clinical and x-ray findings observed in 54 cleft hands of 31 patients. The emphasis was on a detailed analysis of typical malformation-associated x-ray patterns such as aplasia and synostosis, with findings arranged as a function of cleft location and of the Manske and Halikis classification. METHODS: The charts and radiographs of 31 patients with 54 cleft hands were reviewed retrospectively and compared with data reported in the literature. Important clinical and x-ray findings as well as the typical morphology of cleft hands were analyzed. Cleft hands were differentiated according to their location and according to the Manske and Halikis classification. In the different locations the deformities were arranged in teratologic sequences. RESULTS: In cleft hands syndactylies were seen in 30 of the 54 hands, most commonly between the ring and the small finger. In 3 hands polydactylies were noted. Analysis of the x-ray morphology showed 2 typical patterns: aplasia and synostoses. Location-specific teratologic sequences showed that radial cleft hands were bilateral more frequently and were associated significantly more frequently with cleft feet. Aplasias predominated in radial cleft hands, whereas synostoses were more common in central cleft hands. In terms of the Manske and Halikis classification the unilateral cleft hands often corresponded to type I whereas bilateral cleft hands with cleft feet mainly were type IV and type V deformities. Cleft hands with synostoses often were seen in types I to III whereas cleft hands with aplasias were classified most frequently as type V. CONCLUSIONS: Analysis of the patients' clinical data and x-rays showed differences between radial and central cleft hands, as well as between the different Manske and Halikis types.     

Partielle Verdoppelung eines Fußes

The Problem Complex deformity with partial duplication of the left foot in an 8-month-old girl with numerous other congenital deformities. Marked broadening of the foot due to three additional toe rays and tarsal bones. The Solution Resection of the three intermediate supernumerary toe rays and narrowing of the foot by wedge resection of the corresponding tarsal bones. Fibular transposition of both peroneal tendons. Construction of a deep transverse metatarsal ligament around the two metatarsals adjacent to the cleft. Surgical Technique Elliptic dorsal and plantar incision around the three supernumerary toes and their excision. Through partial excision of the tarsal bones, the width of the foot is reduced. Lateral transposition of both peroneal tendons. Construction of a deep transverse metatarsal ligament using one extensor tendon of a supernumerary toe to hold both parts of the foot in close approximation. The extensor tendon of the second remaining toe counted from fibular that runs in an abnormal direction is attached to the proximal tendinomuscular stumps of the excised toes. The skin tag at the fibular side of the foot is resected. Result Eleven years later, the girl is able to wear normal shoes and has minimal complaints after prolonged walking. The scars are barely visible and not sensitive to pressure. The mobility of the fibular toes is slightly reduced; also the range of motion of the subtalar joint is limited by 50%. The radiologic aspect of some tarsal bones is unusual, but with smooth articular surfaces.     

Macrodactyly of the foot

BACKGROUND: The purpose of this study was to focus on the problems associated with macrodactyly of the foot and to formulate guidelines for optimum treatment. METHODS: Seventeen feet (fifteen patients) with macrodactyly formed the basis of this retrospective review. The feet were classified into one of two groups, depending on whether the macrodactyly involved only the lesser toes (group A) or involved the great toe with or without involvement of the lesser toes (group B). Toe amputation or ray resection was usually done to reduce the length and width of the foot in group A, whereas the length of the first ray was reduced by epiphysiodesis or amputation of the phalanx in four of the five feet in group B. In both groups, soft-tissue debulking was an integral part of the treatment. The severity of the macrodactyly and the effect of treatment were documented radiographically by measurement of the so-called metatarsal spread angle. At the latest follow-up evaluation, each foot was graded with regard to pain and shoe wear. RESULTS: Toe amputation was performed in six of the twelve feet in group A and toe shortening was performed in two, but only three of those procedures had a good result. Ray resection was performed in five feet (as an initial or secondary procedure) in Group A, and all had a good result. The mean reduction of the metatarsal spread angle was 10.0 degrees following resection of a single ray in Group A. In Group B, four of the five feet were rated as having only a fair result because shortening alone did not effectively reduce the size of the great toe. The macrodactyly of the great toe was not treated in the fifth foot, which also had a fair result. CONCLUSIONS: Toe amputation, which is cosmetically unappealing, is not effective for treating macrodactyly of the lesser toes and does not address the enlargement of the forefoot. Ray resection results in the best cosmetic and functional outcomes in feet with involvement of the lesser toes. When the great toe is involved, the result is often only fair, and repeated soft-tissue debulking may be necessary.     

巨趾畸形12例临床分析

目的 总结巨趾畸形的临床特点和手术疗效.方法 回顾性分析12例巨趾畸形患者的临床资料.共12例(13足)患者,其中男性8例,女性4例,平均年龄4.6岁.均在出生时被发现畸形.多趾巨大畸形患者多于单趾畸形的患者,胫侧足趾好发.对应的前足均粗大.巨趾的趾骨均粗长,部分对应的跖骨粗长.术中见所有患者均有皮下脂肪过度增生,侵犯骨间肌和关节囊.足部神经和分支无明显增粗,无脂肪浸润.手术包括软组织缩容、骺阻滞、截趾、神经切断再吻合等.结果 7例患者获得随访,随访时间平均25.6个月.根据自行制订的分级标准进行功能评定:优2例,良2例,中3例.结论 手术治疗巨趾畸形有效,应重视手术适应证、手术时机和术式的选择.     

Classification of polydactyly of the hands and feet

The authors present a new classification of polydactyly based on radiomorphological alterations. The malformations are defined in two directions, as in a system of coordinates. The longitudinal arrangement is based on the pathogenetic principle of bifurcation of a finger or a toe ray from distal to proximal. We accordingly divided polydactylies into five types: distal phalanx, middle phalanx, proximal phalanx, metacarpal or metatarsal, carpal or tarsal. The transverse arrangement indicates which rays are involved. All polydactylies, including the special forms such as rudimentary manifestations, triphalangism, and multiple duplications, can be incorporated into this simple basic scheme. Depending on their characteristics, the special forms are further subdivided, e.g., into a distal or proximal phalanx type with simple or double triphalangism, or a tarsal type with third-degree duplication and first-degree aplasia. Numerous radiological examples and schematic drawings illustrate the classification. The advantage of the classification is that it depends exclusively upon the skeletal finding and all manifestations are registered according to a simple scheme longitudinally and transversely. This makes them codifiable for the computer and suitable for multicenter studies. The special forms, the rudiment, triphalangism, and multiple duplication, can easily be further subclassified. Moreover, the nomenclature is simple and is oriented to anatomical terminology.     

Surgical correction of severe claw toe deformity: a review of the Stainsby procedure

In the severely clawed lesser toe, the plantar plate of the metatarso-phalangeal joint becomes displaced onto the dorsal aspect of the metatarsal head and causes it to be depressed. The results of a surgical procedure replacing the plantar plate to its correct position are presented.Thirty feet in 23 patients have been reviewed. Preoperatively, all patients had metatarsalgia as a result of severely clawed lesser toes. The average age was 60 years (26–84 years) and the average follow-up period was 23 months (6–62 months).In 18 feet (56 toes), the deformities were due to rheumatoid arthritis. Eight feet (10 toes) had lesser toe deformities secondary to hallux valgus, and in three feet (3 toes) there was no obvious cause. One patient had severe clawing of two toes as a result of long-standing missed traumatic dislocations of the metatarso-phalangeal joints.In the rheumatoid group, 12 feet (67%) were rated as excellent, four feet (22%) were good, one (5.5%) fair and one (5.55%) had poor results. In the non-rheumatoid feet, six (49.9%) wererated as excellent, five (41.6%) were rated as good, and one (8.3%) had a fair result.     

Modified resection arthroplasty for infected non-healing ulcers with toe deformity in diabetic patients

BACKGROUND: Diabetic motor neuropathy is expressed as the loss of function and the contracture of the intrinsic muscles of the foot, leading to the classic claw toe deformity. This deformity predisposes the foot to ulcerations on the dorsum or tip of the toes or an interdigital ulcer over a condyle between the toes. We present our results of a modified resection arthroplasty for the treatment of this difficult problem. MATERIALS AND METHODS: In this study, 72 toes (57 feet) with a deformity in the second to fifth toe accompanied by chronically infected ulcers were involved. All patients underwent modified resection arthroplasty of the PIP or DIP joint depending on the ulcer location. The second toe was involved in 27 cases (38%), the third toe in 11 cases (15%), the fourth toe in 19 cases (26%), and the fifth toe in 15 cases (21%). With the exception of 4 patients, all had a positive culture, including 7 cases of MRSA. The mean followup was 28.7 +/- 8.1 months. RESULTS: The mean wound healing time was 25.6 +/- 6.2 days. Three cases eventually required toe amputation but there was no proximal spread of infection. No recurrence of a claw toe or ulcer occurred in the remaining toes. CONCLUSION: We believe that modified resection arthroplasty for toe deformities with chronic infected ulcers in diabetic patients is a good treatment alternative to toe amputation.     

Amputation und Exartikulation der Kleinzehen

Objective

Amputations and exarticulations of the toes may be necessary due to several reasons. The goal is to remove necrosis or infection prior to its spread to the midfoot region. From a functional or cosmetic point of view, amputation/exarticulation of a single toe plays no major role. However, this can be different with exarticulation of several toes.

Indications

Necrosis, trauma, infection, tumor, deformity.

Contraindications

Conditions where amputation/exarticulation of a toe is insufficient, e.?g., in progressing peripheral arterial disease.

Surgical technique

The toe can either be amputated through the distal phalanx or exarticulated in the metatarsophalangeal joint.

Postoperative management

Orthopedic shoes or orthotic devices are rarely necessary when a single toe is amputated/exarticulated. However, concomitant deformities of the foot have to be thoroughly addressed. If more than one toe is amputated, silicone spacers may be necessary to prevent the remaining toes from deviating.

Results

Amputations and exarticulations of the toes are frequent and the procedure is technically simple. However, the complication rate is high due to typical indications making amputation necessary.

     

Long-term results of the modified Hoffman procedure in the rheumatoid forefoot

BACKGROUND: Rheumatoid arthritis commonly affects the forefoot, causing metatarsalgia, hallux valgus, and deformities of the lesser toes. Various types of surgical correction have been described, including resection of the lesser-toe metatarsal heads coupled with arthrodesis of the great toe, resection arthroplasty of the proximal phalanx or metatarsal head, and metatarsal osteotomy. We report the results at an average of five and a half years following thirty-seven consecutive forefoot arthroplasties performed in twenty patients by one surgeon using a technique involving resection of all five metatarsal heads. METHODS: All patients were treated with the same technique of resection of all five metatarsal heads through three dorsal incisions. All surviving patients were asked to return for follow-up, which included subjective assessment (with use of visual analogue pain scores, AOFAS [American Orthopaedic Foot and Ankle Society] foot scores, and SF-12 [Short Form-12] mental and physical disability scores), physical examination, and radiographic evaluation. RESULTS: All results were satisfactory to excellent in the short term (six weeks postoperatively), and no patient sought additional surgical treatment for the feet. A superficial infection subsequently developed in two feet, and two feet had delayed wound-healing. At an average of 64.9 months postoperatively, the average AOFAS forefoot score was 64.5 points and the average hallux valgus angle was 22.3 degrees . There were no reoperations. CONCLUSIONS: Resection of all five metatarsal heads in patients with metatarsalgia and hallux valgus associated with rheumatoid arthritis can be a safe procedure that provides reasonable, if rarely complete, relief of symptoms.     

Valgus toe deformity of fourth proximal phalanx due to osteochondroma treated with closing wedge osteotomy

Osteochondroma is the most common benign tumor of all benign and primary bone tumors. It rarely occurs in the proximal phalanx of the lesser toe. The treatment of osteochondroma usually consists of simple resection. However, if other deformities remain, added procedures may be considered. We report a case of a valgus toe deformity of the fourth proximal phalanx due to osteochondroma. The patient was a 21-year-old man who noticed a valgus deformity of his fourth toe over 10 years earlier. He began to experience pain in his fifth toe because of crossover of the fourth toe when wearing formal shoes. Although resection of osteochondroma was performed, the valgus deformity was not sufficiently corrected. Therefore, closing wedge osteotomy of the proximal phalanx was performed at the same time. A good outcome was achieved for this patient.     

Resection arthroplasty of the metatarsophalangeal joints after Clayton (10 years of clinical experience) (author's transl)]

57 resection arthroplasties of the metatarsophalangeal joints using the method of Clayton were performed in arthritic and arthrotic deformities of the forefoot. 43 feet were controlled after an average of 5 years postoperatively. The good postoperative position of the toes changes into a progressive shortening, dorsal transposition and frequently valgus direction of the toes during the first year after operation. The deformity is much less than preoperatively. Passive mobility is good, but there is little active motion. The splay foot deformity is reduced in 50% of the cases. No arthritic recurrences were observed, callosities, clavi and mild pain were rarely found. Foot movements, walking ability was improved in all patients and 50% were wearing standard shoes. The results are influenced negatively by errors in resection technique, particularly lack of plantar rounding, exaggerated resection and unfavourable differencies in length of the metatarsal bones, and occasionally by secondary ossifications.     

Keller手术治疗拇外翻疗效分析

目的观察Keller手术治疗     

Syndaktylien und Synostosen am Fuß bei einem Schnürring-Syndrom

The Problem

Seventeen-month-old girl with a complex deformity of the left foot, as evidenced by syndactylies and synostoses between third, fourth, and fifth toes caused by a ring-constriction syndrome.

The Solution

Separation of syndactylies and synostoses, skin coverage with advancement flaps from the dorsum and the sole of the foot, and full-thickness skin grafting in two stages.

Surgical Technique

Separation of soft tissue and bony connections between the three toes. Coverage of the exposed bones by advancement flaps from the dorsal and plantar surfaces of the foot. Skin closure over the site of syndactyly between third and fourth toe could only be achieved partially due the precarious blood supply of the flaps. Completion of the separation 8 months later (stage II) and creation of deep web spaces using dorsal and plantar advancement flaps and full-thickness skin grafts.

Result

Complete separation of the three toes with normal web spaces. Remaining rotational deformities do not interfere with function. Improved appearance of the foot. Ability to wear normal shoes.     

Effect of walking speed on pressure distribution of orthopedic shoe technology

Lesions to the diabetic foot have various causes. However, there is broad consensus that excessive plantar pressure plays a major role in the chain of events leading to ulcerations and gangrenes. During walking, on the other hand, peak values of plantar pressure are likely to increase with velocity even in therapeutic shoes. Therefore, the question arises whether a moderate velocity should be recommended to diabetic patients to reduce the risk of foot lesions. In this study, two velocities were compared for different types of therapeutic footwear. The velocities selected were considered moderate (0.7 m/s) and normal (1.3 m/s) for diabetic patients. A specially designed mathematical algorithm (velocity normalization) provided the pressure distributions from a common set of measurements: seven trials at different velocities for each subject and each type of footwear. Ten test subjects with healthy feet were studied. The shoes were ready-made and all had a midfoot rocker. The following four conditions were tested: flexible or rigid outsole respectively in combination with a flat insole or molded foot bed respectively. Pressure distribution measurements were performed with the Pedar in-shoe system, and the Pedar software package was used for analysis. The foot was divided into six regions: first toe, second to fifth toes, metatarsal region, medial midfoot, lateral midfoot, and heel. Only peak pressures were taken into account. Gait velocity was found to have an effect on plantar pressure distribution, mainly in the toes and heel region. Peak pressure in the heels increased significantly by about 20%. In the toe region, the increase was about the same, but was not statistically significant. At a higher velocity, pressure even slightly decreased in the midfoot region. The percentage variation was similar for all four conditions. Thus, walking slowly prevented the foot from high peak pressures, and the combination of rigid outsole and molded foot bed was best suited for both slow and higher velocities.     

The bifid great toe: a surgical approach

The surgical treatment of bifid great toes has not generated as much interest as that of its upper extremity counterpart. Early treatment of this foot deformity is necessary for ease of shoe wear and cosmesis. Five feet surgically corrected by a variation of the Bilhaut-Cloquet procedure were followed up for 4 years. Because of postoperative nail bed deformities, the nail splitting incision of Bilhaut-Cloquet should be avoided.     

Painful and tender toe,osteoid osteoma of the distal phalanx of toe,a diagnostic dilemma

Osteoid osteoma rarely involves the phalanges of the toes. Basically osteoid osteoma is often a diagnostic dilemma in musculoskeletal practice especially in the foot and ankle. Its presentation is confusing and this may result in delayed diagnosis. We have reported a case of osteoid osteoma of the distal phalanx of the second toe which was treated successfully with surgical excision and reviewed the literature.     

Keller手术治疗外翻疗效分析

目的 观察Keller手术治疗(足母)外翻疗效。方法 对我院1978年1月-1995年12月间因(足母)外翻住院并行了Keller矫形术的病人进行随访,共随访到70例(118足)有效病人。术后时间为5～24年,平均9年,对(足母)趾及前足部症状改善,畸形矫正程度,足趾功能及术后各种并发症进行统计和分析,同时通过负重足印观察比较Keller矫形术对前足负重点的影响。结果Keller手术后病人(足母)趾及前足症状改善,(足母)外翻及叠趾畸形、矫正满意者98足,手术优良率为83％。并发症主要为(足母)趾麻木,(足母)外翻复发或未矫正,(足母)内翻,(足母)抓地力量弱,第二趾屈曲挛缩等,部分病人需要再次手术。结论 Keller手术通过(足母)跖近节趾骨截骨及(足母)跖趾关节成形,以达到(足母)外翻矫正的目的。对年龄较大、(足母)外翻严重,或同时合并(足母)跖趾关节骨关节炎的患者是一个较好的治疗方法。近节趾骨截骨是手术成功的关键。     

Treatment of feet deformities in epidermolysis bullosa

Background

Inherited epidermolysis bullosa is a rare disease characterised by mechanical fragility of the skin when under insignificant stress. The main consequences of epidermolysis bullosa, mainly the dystrophic type, despite pseudosyndactyly, are joint contractures and deformities in hands and feet. In this study, we describe our experience treating patients suffering from epidermolysis bullosa, as far as feet deformities are concerned.

Methods

This is a retrospective analysis of a consecutive series of patients presenting feet deformities related to epidermolysis bullosa. Extension contractures of the toes, equinus and cavus deformities were treated with soft tissues surgery.

Results

Thirteen surgical procedures were done in six patients with feet deformities caused by epidermolysis bullosa. Of the feet operated 85.7 % extension contracture of the toes was asymptomatic at follow-up. However, 42.9 % developed hammertoe deformities. There were no recurrence or complications for other deformities. Subjectively, all patients declared themselves very satisfied with the results.

Conclusion

Foot deformities must be treated as early as possible, due to progressive disability for walking and pain symptoms. We considered that, despite long term complications, treatment was adequate and we recommend it. Level of Evidence Level IV.

     

Presentation of a flap web space laterodigital in cleft foot

Cleft foot deformity is characterized by the absence of one or more median rays of the foot. This rare polymorphous congenital anomaly occurs more frequently in males, with a frequent autosomal dominant type of transmission. The purpose of surgical treatment is to narrow the width of the foot, but also to improve its global aesthetic look. Toe reparation, and more specifically web space reconstruction, provide the main technical challenges. We present an adaptation to the foot of a laterodigital cutaneous flap published by Barsky in 1964 for commissural reconstruction in cleft hand syndroms. The anatomical structure of fingers and toes commisures being different, this flap seems more adapted to the surgery of the foot. We gathered seven patients' files treated for ectrodactyly of the foot with this technique by the same surgeon from 2005 to 2008. No particular postoperative complications were noted, and the patients all expressed their satisfaction regarding the improvement of the appearance of their foot. We recommend to add the use of this flap in the "tool box" of the surgeon in charge of the management of foot deformities.