Minimally invasive correction for symptomatic,fixed curly toe deformity

BackgroundCurly toe deformity is a relatively common deformity that generally occurs at the 4th and 5th proximal and/or middle phalanges but rarely presents with symptoms. Although numerous open operative techniques have been introduced, there is no established treatment yet. We report the results of minimally invasive correction for symptomatic, fixed curly toe deformity.MethodsBetween 2016 and 2018, 25 consecutive percutaneous dorsolateral closing wedge-shaped osteotomies with Shannon burrs at the proximal and/or middle phalanx were performed. We assessed the postoperative clinical and radiological changes at a mean of 22.51 months of follow-up.ResultsThe locations of osteotomy were at the middle phalanx in 10 cases, proximal phalanx in 13 cases, and both in one case. The mean amount of corrections of varus inclination and shortening were 16.54° and 2.24 mm, respectively. The Foot and Ankle Ability Measure Activities of Daily Living scores significantly improved from 59.09 preoperatively to 74.55 at the last follow-up. There was one case of pin site infection and one case of incision site numbness due to digital nerve injury.ConclusionsMinimally invasive dorsolateral closing wedge-shape osteotomy is a simple, safe, and effective correction for symptomatic, fixed curly toe deformity.     

Surgical correction for curly toe using open tenotomy of flexor digitorum brevis tendon.

Curly toe is a common congenital deformity characterized by flexion and varus deformity of the interphalangeal joints. Because this minor deformity is seldom accompanied with any symptoms, treatment strategy has rarely been discussed in detail in the literature. Eight toes in seven patients with curly toe were treated by open tenotomy of the medial slip of the flexor digitorum brevis tendon. If sufficient correction was not obtained, the collateral ligament and the volar plate of the proximal interphalangeal joint were dissected. The skin defect at the plantar base of the toe was covered using a local flap or a full-thickness skin graft. The median age at operation was 2 years 6 months (ranged from 8 months to 5 years 4 months). In all cases, contracture of the plantar skin at the base of the toe and tight FDB tendon were recognized to a variable degree. Postoperatively, overlapping of the affected toe was corrected in every case at a median follow-up of 2 years 9 months. However, flexion and/or varus deformity tended to remain to some degree in those patients with severe curly toe. Toes with moderate to severe deformity with overlapping beneath the adjacent toe are candidates for surgical correction, because spontaneous correction is unlikely and troublesome symptoms may occur as the child grows older. Surgical correction should be performed until 2-3 years of age. The postoperative result might be poor, if treated in the older age, because skeletal deformity is likely to occur. Open tenotomy of the FDB tendon is easy to perform, and toe function was seldom impaired.     

Lambeau hétéro-digital selon le principe du « doigt banque » prélevé chez un orteil dupliqué pour le traitement d’un flessum cutané d’une clinodactylie associée

IntroductionThe correction of cutaneous deficiency encountered in clinodactyly is an important aspect of its treatment. The use of the skin lining of an adjacent duplicated toe as a « spare-part » flap may be of interest in providing good quality tissue.Clinical caseWe report the case of a child with complete duplication of the 5th toe associated with clinodactyly. The use of a heterodactyl flap taken from the amputated toe allows the release of a plantar cutaneous flange of the preserved toe.DiscussionThe concept of « spare-part » flap is mainly used in hand surgery in traumatic lesions of the fingers. Its application in the treatment of clinodactyly on the occasion of the regularization of a polydactyly is also interesting because some fingers or toes are intended to be amputated to render a classical anatomy of five-toed foot. It is necessary for the realization of this type of flap on malformative toes to verify the existence of a distinct viable pedicle of the amputated toe, which can be done only intraoperatively.ConclusionThe surgery for congenital malformations of the toes requires perfect management of the skin capital. The use of a « spare-part » toe flap taken from the toe to be amputated is a viable solution for the treatment of a cutaneous flessum encountered in a clinodactyly of the adjacent finger.     

Flexor tendon lengthening for hammer toes and curly toes in paediatric patients

The purpose of this retrospective study was to evaluate the outcome of flexor tendon lengthening performed for hammer toes or curly toes in children, after a mean follow up of 31 months. Specific attention was given to postoperative active flexion of the toe. The deformity improved in all patients, but less in the fourth and fifth toe. Active flexion returned and strength was recovered in all patients. We think that open flexor tendon lengthening for hammer and curly toes is a safe and reliable procedure. We recommend a transverse skin incision, Z-lengthening of the flexor digitorum longus in hammer toes and an associated tenotomy of the flexor digitorum brevis in curly toes.     

Midterm Results of Resection Arthroplasty for Forefoot Deformities in Patients with Rheumatoid Arthritis and the Risk Factors Associated with Patient Dissatisfaction

We investigated the midterm results of resection arthroplasty of all 5 metatarsal heads in patients with rheumatoid arthritis and forefoot deformity and analyzed the factors that affect patient satisfaction levels. Of 64 patients (1 male, 63 females), 107 feet were treated with resection arthroplasty for forefoot deformity at our hospital from January 1992 to December 2005. The mean follow-up period was 5.8 ± 3.1 years, with all patients having at least 1 year of follow-up. Of the 64 patients, 75% were satisfied with the surgery. The mean score for the postoperative Japanese Society for Surgery of the Foot lesser metatarsophalangeal-interphalangeal scale was 75.0 ± 15.8 points. Multivariate logistic regression analysis showed that patient-reported dissatisfaction was significantly associated with the recurrence of hammer toe deformity (odds ratio 2.66, 95% confidence interval 1.07 to 6.97), shortening of the resection arthroplasty space (odds ratio 0.85 for a 1-unit increase, 95% confidence interval 0.74 to 0.96), and the recurrence of hallux valgus (odds ratio 1.04 for a 1-unit increase, 95% confidence interval 1.00 to 1.09) during the postoperative period. From our results, interventions to prevent recurrence of hammer toe deformity, especially in toes with preoperative metatarsophalangeal joint dislocations, have been shown to be important in preventing complications and patient dissatisfaction after resection arthroplasty.     

Open flexor tenotomy for hammer toes and curly toes in childhood

Sixty-two children were reviewed between 3 and 14 years (average 9.8 years) after flexor tenotomy for curly toes or hammer toes. No patients were aware of loss of flexor power in the toes. In only 5% of 188 toes was the operation unsuccessful. When the cause of failure was identifiable it proved to be that the scar crossed one or more flexor creases. None of the operated toes had an abnormally extended posture; only one toe was stiff and this resulted from tethering by a scar. It is concluded that open flexor tenotomy is an effective method for correcting curly toes and hammer toes in childhood. Pre-operative assessment must demonstrate that the resting length of the flexor tendons is unduly short, and that this shortening is the only cause of the deformity.     

Komplikationen chirurgischer Eingriffe an den Kleinzehen

BackgroundLesser toe surgeries are among the most commonly performed surgical procedures in foot and ankle surgery. A large number of pathologies caused by an imbalance of the extrinsic and intrinsic muscles encounter an even greater number of surgical techniques. For the most part, patient satisfaction and clinical results are very good, but if complications occur, these often result in pain and can cause serious disability for the patient.MethodsDepending on the correctability of the deformity (flexible vs. rigid), either bony corrections including osteotomies (e.g. Weil), arthrodesis (PIP, DIP), and arthroplasty (trochlear resection arthroplasty), or soft tissue procedures (e.g. tendon transfers, tendon lengthening, reconstructions of the plantar plate) are used.ResultsComplications can generally be divided into 4 categories: wound complications, malalignment, neurological complications and implant-related complications. Superficial wound infections are common and can be managed with conservative measures and oral antibiotics. In contrast, hypoperfused toes, fixed dorsiflexion contracture, or deep infections are serious complications.ConclusionComplications following lesser toe surgeries are as diverse as the underlying pathologies. Amputation of the toe as a last resort is not uncommon, especially in cases of severe infection, circulatory disorders or recurrent malalignment.     

Strapping of curly toes in children

This is a retrospective review of 49 children with curly toes treated by strapping; 24 children (44 toes) presented for review. The strapping produced improvement in 68% of toes while strapping was maintained, but there was a statistically significant loss of correction once strapping was stopped. There was some sustained improvement in the shape of the toes compared with the natural history, but not sufficient to warrant its use for this minor congenital deformity. Treatment should be reserved for the more severely deformed toe, as this may cause symptoms in later life, and the author recommends open flexor tenotomy.     

糖尿病伴足趾畸形的三维动态足底压力分析

目的探讨糖尿病伴足趾畸形的足底压力分布特征及其临床意义,评价三维动态足底压力分析技术在该症诊疗中的应用价值。方法选取32例糖尿病伴锤状趾、爪形趾及多发足趾畸形患者及32例健康自愿者,分为病例组和对照组。两组年龄、性别组成、体重指数近似,且经规范的行走训练后,应用三维动态足底压力分析系统（F-scan Mobile,Tekscan,USA）,测量对比分析病例组及对照组的足底总峰值压力及足拇趾、第1～5跖骨头、中足、后足等7个解剖区域平均峰值压力分布的差异。结果病例组及对照组在一个步态周期中的足底总峰值压力、第1～5跖骨头及后足的平均峰值压力存在较大差异（P〈0.05）,其中病例组第1、2跖骨头底部压力（302.5±34.8kPa,375.2±47.1 kPa）较对照组（242.8±19.3 kPa,253.7±22.1 kPa）明显增高;两组中足平均峰值压力差异无明显统计学意义（P〉0.05）;病例组后足平均峰值压力较对照组明显降低（P〈0.05）。结论糖尿病伴足趾畸形可使跖骨头下的压力增高。三维动态足底压力分析技术可早期检测该病理力学变化,从而对预防糖尿病足部溃疡形成及指导治疗具有较大的应用价值。     

Incidence of thyroid disease in patients with forefoot deformity

BackgroundHallux valgus and lesser toe deformities are common foot disorders with substantial functional consequences. While the exact etiologies are multi-factorial, it is unknown if certain endocrine abnormalities, such as thyroid dysfunction, may be associated with these pathologies. The current study sought to investigate the prevalence of thyroid disease in patients with hallux valgus or lesser toe deformities.MethodsEvery new patient who presented to our institution’s foot and ankle clinic during a three-month time period was given a survey to determine the presence of a known thyroid disorder. The diagnosis for each visit was then recorded. Additionally, a national, publicly available database was queried for patients diagnosed with thyroid disease and concomitant hallux valgus or specific forefoot pathology. Odds ratios for the presence of thyroid dysfunction were then calculated for each patient group.ResultsThree-hundred and fifty initial visit patient surveys were collected, and 74 (21.1%) patients had a known diagnosis of thyroid disease. The most common diagnoses were primary hypothyroidism (n = 61, 17.4%), secondary hypothyroidism (n = 6, 1.7%), thyroiditis (n = 4, 1.1%), and hyperthyroidism (n = 3, 0.9%). Thyroid disease was present in 16 of 26 patients (61.5%) with a diagnosis of hallux valgus (OR 7.3, CI[3.16–16.99], p < 0.0001). Lesser toe deformities, including hammertoes, mallet toes, bunionettes and crossover toes, were also significantly associated with thyroid disease (OR 5.45, CI[1.83–16.26], p < 0.002). The national database revealed 905,924 patients with a diagnosis of a specific forefoot deformity, and 321,656 of these patients (35.5%) had a concomitant diagnosis of a thyroid condition (OR 2.11, CI[2.10–2.12], p < 0.0001).ConclusionsThe current study suggests a significant association between forefoot pathology and thyroid dysfunction, especially hallux valgus and lesser toe deformities. Increased understanding of these correlations may offer an important opportunity in population health management, both in diagnosis and treatment. While further studies with long-term outcomes are necessary, the early diagnosis of thyroid disease may provide an opportunity to predict and potentially alter the course of forefoot pathology.     

Podoscopic classification of second toe deformities

BackgroundThe AFCP (French Association of Foot Surgery) classification was recently introduced as a reliable and quick visual method for the assessment of sagittal plane deformities of the second toe. The aim of this study was four-fold: (1) to describe a new toe-ground area score (TAS) as an additional dynamic tool of such classification, (2) to verify whether all second toe deformities could be classified, (3) to assess the TAS intra- and inter-observer reliability and (4) to evaluate the TAS learning curve.MethodsIn this retrospective study 52 s toes were evaluated using a podoscope. Ten foot and ankle surgeons assessed independently standardised videos of each case acquired in a blinded fashion. Assessment was repeated three times, 15 days apart. Intra- (Intraclass Correlation Coefficient or ICC) and inter-observer reliability (Fleiss’ Kappa coefficient) were calculated. Mean time to assess a deformity was also recorded.ResultsAll the 522 observations (52 feet assessed by 10 surgeons) were successfully rated using the TAS. Intra- and inter-observer reliability were substantial for the first round (ICC: 0.79; Kappa: 0.76) and excellent for the second (ICC: 0.88; Kappa: 0.8) and third round (ICC: 0.84; Kappa: 0.81). Mean assessment time ± standard deviation was 22 ± 11 s per case for the last two rounds.ConclusionsThe TAS has been proven reliable and quick in the assessment of second toe deformities. When combined with a static segmentary classification of the toe (such as the AFCP classification) it might provide further dynamic informations about the ability of the toe to engage the ground.Level of evidenceLevel IV, retrospective cohort study.     

A novel modification of the Stainsby procedure: Surgical technique and clinical outcome

BackgroundThe ‘Stainsby procedure’ is an effective salvage procedure for correction of fixed claw toe deformity. A novel approach is described involving the extensor tenotomy step of the procedure, which is easier, faster and safer to perform.MethodsA retrospective single surgeon review was performed to assess this modification. 37 patients (92 lesser toes in 42 feet) underwent the modified Stainsby procedure. Mean follow-up was 17 months. Patients were interviewed and examined at a dedicated review clinic. American Orthopaedic Foot and Ankle Society (AOFAS) forefoot scores and Foot and Ankle Outcome (FAO) scores were calculated.ResultsSignificant improvements in end-points including metatarsalgia, callosity and requirement for insoles or chiropody were noted. Median AOFAS and FAOS scores following the modified Stainsby procedure are reported and compare favourably to previously reported scores. Median FAOS scores were as follows: 92 for the category of pain, 84 for symptoms and stiffness, 96 for activities of daily living, 100 for sports and recreation and 81 for quality of life. Median AOFAS forefoot score was 80. There was a low rate of wound infection of 2.7% (n = 1).ConclusionWe describe a novel technical modification to the Stainsby procedure and our results support the use of this modification, following assessment of patient outcome. However, limitations to this study were noted in terms of the length of follow-up, the absence of pre-operative clinical scores for comparative purposes, and the variety of surgical procedures performed concomitantly on the 1st ray.     

Treatment of metatarsalgia based on claw toe deformity through soft tissue release of the metatarsophalangeal joint and resection of the proximal interphalangeal joint: Evaluation based on foot kinematics and plantar pressure distribution

IntroductionThis study investigated the effect of operative claw toe correction with release of the metatarsophalangeal (MTP) joint, repositioning of the plantar fat pad and resection of the proximal interphalangeal joint on foot kinematics, plantar pressure distribution and Foot Function Index (FFI).MethodsProspective experimental study with pretest-posttest design. The plantar pressure, 3D foot kinematics and the FFI of 15 patients with symptomatic claw toes were measured three months before and 12 months after surgery. Mean pressure, peak pressure and pressure time integral per sensor and various foot angles were calculated for the pre- and posttest and compared to a control group (N = 15).ResultsClaw toe patients have increased pressure under the distal part of the metatarsal head and less pressure under the proximal part of the metatarsal heads compared to healthy controls. After surgery, there was a redistribution of pressure, resulting in a significant decrease of pressure under the distal part and an increase under the proximal part of the metatarsal head, providing a more equal plantar pressure distribution. Except for some small areas under the forefoot, heel and toes, there were no significant differences in pressure distribution between the operated feet and controls. Small, but significant differences between the pre- and postoperative condition were found for the lateral arch angle, calcaneus/malleolus supination and tibio-talar flexion. The score on the FFI improved statistically significant.DiscussionThese findings imply that the present operative procedure results in a more equal distribution of the plantar pressure under the forefoot and decrease of pain and offers successful treatment of metatarsalgia based on claw toe deformity.     

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.     

Correlation of spinopelvic parameters with functional outcomes in surgically managed cases of lumbar spinal tuberculosis- A retrospective study

BackgroundThe advanced stage of vertebral involvement in spinal tuberculosis (STB) can cause vertebral body collapse, which leads to kyphotic deformity and paraplegia in severe cases. Surgery is indicated in patients having disabling back pain, progressive neurological deficit, and instability in spine despite conservative management. The derangement of lumbar parameters, especially the loss of lumbar lordosis has been found to cause functional deterioration in patients. With the current evidences in place, this study was done to evaluate the correlation between the restoration of lumbar lordosis, pelvic parameters, and functional outcome when posterior only approach was used to manage the lumbar STB.MethodsActive Tuberculosis of lumbar vertebra (L1-S1) confirmed by radiology (X-ray, MRI) and histopathological examination were included. All the cases scheduled for surgery underwent radiographs, CT scan, and MRI scans. Lumbar lordosis and other pelvic parameters were calculated on X-rays. VAS scores and ODI scores were documented during the follow-up to assess functional well-being.ResultsA total of 33 (22 M:11 F) patients were included in the study. The mean lumbar lordosis pre-operatively was −22.84 ± 11.19° which was corrected to −37.03 ± 9.02° (p < 0.05) post-operatively. The pelvic tilt pre-operatively was 25.33 ± 6.75° which was corrected to 19.63 ± 5.84° (p < 0.05) post-operatively. The mean ODI improved from 84.33 ± 11.84 to 26.93 ± 8.74 (p < 0.05) at the final follow-up. The mean VAS score pre-operatively was 8.06 ± 1.27 which improved to 2.45 ± 0.93 (p < 0.05) in the post-operative period.ConclusionThe study found a strong negative correlation between ODI scores and lumbar lordosis and a strong positive correlation between pelvic tilt and ODI scores. But the correlation needs to be further studied and evaluated by a well-constructed study especially with a control group treated conservatively.     

Reliability and validity of measures of hammer toe deformity angle and tibial torsion

BackgroundMeasures of second–fourth metatarsophalangeal joint (MTPJ) angle (indicator of hammer toe deformity) and clinical measures of tibial torsion have limited evidence for validity and reliability. The purposes of this study are to determine: (1) reliability of using a 3D digitizer (Metrecom) and computed tomography (CT) to measure MTPJ angle for toes 2–4; (2) reliability of goniometer, 3D digitizer, and CT to measure tibial torsion; (3) validity of MTPJ angle measures for toes 2–4 using goniometry and 3D digitizer compared to CT (gold standard) and (4) validity of tibial torsion measures using goniometry and 3D digitizer (Metrecom) compared to CT (gold standard).MethodsTwenty-nine subjects participated in this study. 27 feet with hammer toe deformity and 31 feet without hammer toe deformity were tested using standardized gonimetric, 3D digitizer and CT methods. ICCs (3,1), standard error of the measurement (SEM) values, and difference measures were used to characterize intrarater reliability. Pearson correlation coefficients and an analysis of variance were used to determine associations and differences between the measurement techniques.Findings3D digitizer and CT measures of MTPJ angle had high test–retest reliability (ICC = 0.95–0.96 and 0.98–0.99, respectively; SEM = 2.64–3.35° and 1.42–1.47°, respectively). Goniometry, 3D digitizer, and CT measures of tibial torsion had good test–retest reliability (ICC = 0.75, 0.85, and 0.98, respectively; SEM = 2.15°, 1.74°, and 0.72°, respectively). Both goniometric and 3D digitizer measures of MTPJ angle were highly correlated with CT measures of MTPJ angle (r = 0.84–0.90, r = 0.84–0.88, respectively) and tibial torsion (r = 0.72, r = 0.83). Goniometry, 3D digitizer, and CT measures were all different from each other for measures of hammer toe deformity (p < 0.001). Goniometry measures were different from CT measures and 3D digitizer measures of tibial torsion (p < 0.002). CT measures and 3D digitizer measures of tibial torsion were similar (p = 0.112).InterpretationsThese results suggest that 3D digitizer and CT scan measures of MTPJ angle and goniometric, 3D digitizer, and CT scan measures of tibial torsion are reliable. Goniometer and 3D digitizer measures of MTPJ angle and tibial torsion measures are highly correlated with the gold standard CT method indicating good validity of measures, but the measures are not interchangeable.     

逆行法再植在多足趾离断伤治疗中的应用

目的 探讨采用逆行法再植治疗多足趾离断的临床经验及治疗效果.方法 自2013年1月对9例32趾多足趾离断伤患者采用逆行法再植.顺序为清创→缝合跖侧皮肤→缝合趾屈肌腱→吻接趾底固有动脉、神经→趾骨复位固定→缝合趾伸肌腱→吻合趾背静脉→缝合趾背皮肤.结果 9例32趾再植中成活26趾;其中1例左足1-5趾离断伤术后30h,再...