Forefoot tendon transfers

Advances in the Causes and Treatment of Floating Toes after the Weil Osteotomy: A Scoping Review

The floating toe deformity is classified as a forefoot deformity wherein the distal portion of the toe does not establish touch with the ground, resulting in a suspended or elevated position while the finger is in a relaxed state. At first, it garnered considerable interest as a complication It is worth noting that this condition is particularly common in children under the age of 8, which usually disappears as the individual reaches maturity. Studies have shown that with the aggravation of floating toe deformity, its adverse effects on patients' gait and overall quality of life also increase. Despite the prevalence of floating toe deformity in clinical settings, there is a lack of comprehensive literature investigating its underlying causes and potential preventive strategies. This scope review follows the preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews (PRISMA-ScR) statement guidelines for scope reviews. The literature was obtained from various full-text databases, including China National Knowledge Infrastructure Database (CNKI), Wanfang Database, PubMed, and Web of Science Database. Our search focused on published literature related to floating toes, Weil osteotomy, and distal metatarsal osteotomy, up until March 1, 2023. The literature search and data analysis are conducted by two independent reviewers. If there are any disagreements, a third researcher will participate in the discussion and negotiate a decision. Furthermore, two experienced foot and ankle surgeons conducted a thorough literature analysis for this review. Sixty-two articles were included. Through the clinical analysis of the structural changes of the forefoot before and after operation, the classification of floating toe was described, the causes of pathological floating toe were summarized, and the possible intervention measures for the disease were put forward under the advice of foot and ankle surgery experts. We comprehensively summarize the current knowledge system about the etiology of floating toe and put forward the corresponding intervention strategy. We recommend that future studies will focus on the improvement of surgical procedures, such as the combination of Weil osteotomy, proximal interphalangeal (PIP) arthrodesis and flexor tendon arthrodesis.

Diaphyseal Proximal Phalangeal Shortening Osteotomy for Correction of Hammertoe Deformity: Operative Technique and Radiological Outcomes

BACKGROUND

Correction of hammertoe deformities at the proximal interphalangeal (PIP) joint results in an inherent loss of motion that can be a concern for active patients who want to maintain toe function and grip strength. Diaphyseal proximal phalangeal shortening osteotomy (DPPSO) is a joint-sparing procedure resecting a cylindrical portion of the proximal phalanx on the middiaphysis.

PATIENTS/METHODS

This was a retrospective review including patients treated using DPPSO with at least a 1-year follow-up. Demographic, comorbidity, and Visual Analogue Scale (VAS) scores and complication data were obtained. Radiological assessment included union status and alignment. Medial frontal anatomical (mFAA), frontal proximal interphalangeal (mFIA), plantar lateral anatomical (pLAA), and medial and plantar lateral interphalangeal angles (pLIA) were measured.

RESULTS

A total of 31 patients (45 toes) were included, with a mean age of 59 years (range: 24-72) and follow-up of 35 months (range: 12-60; mean preoperative VAS score was 4.9 ± 1.72 improving to 1.62 ± 2.28; P < .01). Union occurred in all patients at an average of 11.2 weeks. Complications were present on 4 toes (8.8%), with no recurrences. The pLIA significantly changed from 44.9° to 17.9°. There were no significant differences in the preoperative and postoperative values of the mFAA, pLAA, and mFIA.

CONCLUSIONS

DPPSO provides adequate pain relief and corrects the PIP joint in the lateral plane without significantly affecting the coronal plane or the anatomical axis of the phalanx in the frontal and lateral views, nor producing secondary deformities. DPPSO is a safe, effective, and reproducible technique with a low complication rate.

LEVELS OF EVIDENCE

Level IV: Retrospective case series.

Anatomy of the Distal End of Flexor Digitorum Longus Tendon and Percutaneous Release Technique: A Cadaveric Study

Background:

The transfer of flexor-to-extensor is widely used to correct lesser toe deformity and joint instability. The flexor digitorum longus tendon (FDLT) is percutaneously transected at the distal end and then routed dorsally to the proximal phalanx. The transected tendon must have enough mobility and length for the transfer. The purpose of this study was to dissect the distal end of FDLT and identify the optimal technique to percutaneously release FDLT.

Methods:

Eight fresh adult forefoot specimens were dissected to describe the relationship between the tendon and the neurovascular bundle and measure the width and length of the distal end of FDLT. Another 7 specimens were used to create the percutaneous release model and test the strength required to pull out FDLT proximally. The tendons were randomly released at the base of the distal phalanx (BDP), the space of the distal interphalangeal joint (SDIP), and the neck of the middle phalanx (NMP).

Results:

At the distal interphalangeal (DIP) joint, the neurovascular bundle begins to migrate toward the center of the toe and branches off toward the center of the toe belly. The distal end of FDLT can be divided into 3 parts: the distal phalanx part (DPP), the capsule part (CP), and the middle phalanx part (MPP). There was a significant difference in width and length among the 3 parts. The strength required to pull out FDLT proximally was about 168, 96, and 20 N, respectively, for BDP, SDIP, and NMP.

Conclusion:

The distal end of FDLT can be anatomically described at 3 locations: DPP, CP, and MPP. The tight vinculum brevis and the distal capsule are strong enough to resist proximal retraction. Percutaneous release at NMP can be performed safely and effectively.

Clinical Relevance:

Percutaneous release at NMP can be performed safely and effectively during flexor-to-extensor transfer.

Treatment of Flexible Lesser Toe Deformities

Lesser toe deformities are among the most common complaints presented to foot and ankle specialists. These deformities present in variable ways, which makes surgical decision making complex. For every type of deformity, there could be a combination of soft tissues and bony procedures, chosen according to the surgeon's preferences. This article first describes modern classification of lesser toe deformities, and then presents the different treatments and procedures available for those flexible deformities. In addition, this article proposes an algorithm based on clinical/radiological evaluation and step-by-step surgical decision making.

Lesser Metatarsophalangeal Joint Instability: Treatment with Tendon Transfers

Complex digital deformities and metatarsophalangeal joint instability encompass a wide range of pathology, and we must identify the different degrees of ligamentous disruption. It is important to address a combination of procedures to treat gross deformities of the lesser toes. Surgical treatment should be individualized and requires a sequential process for adequate reduction and deformity correction. There is no gold standard procedure for every deformity. Although residual stiffness can result from tendon transfer, overall patient satisfaction levels remain high when it is performed under the proper indications and concomitantly with other procedures to gain full correction of these challenging deformities.

The pathology and management of lesser toe deformities

Deformities of the lesser toes are common and can be associated with significant morbidity. These deformities are often multiple, and numerous treatment strategies have been described in the literature.The goal of surgical treatment is to improve symptoms by restoring alignment and function, and avoiding recurrence. In order to achieve this, it is essential for the treating surgeon to understand the normal anatomy and pathology of the various deformities.There is a paucity of prospective studies and randomised-controlled trials assessing the efficacy of specific interventions.We describe the normal anatomy and biomechanics of the lesser toes, and the pathology of commonly adult deformities. The rationale behind various treatment strategies is discussed and the results of published literature presented. Algorithms for the management of lesser toe deformities based on current literature are proposed. Cite this article: Malhotra K, Davda K, Singh D. The pathology and management of lesser toe deformities. EFORT Open Rev 2016;1:409-419. DOI: 10.1302/2058-5241.1.160017.

Extensor Digitorum Brevis Transfer Technique to Correct Multiplanar Deformity of the Lesser Digits

Lesser digital deformities may present a surgical challenge to even the most skilled foot and ankle surgeon. Multiplanar toe deformities, including the crossover toe, are especially difficult to correct with reproducible results. Undercorrection, pain, stiffness, and recurrent deformity are well reported throughout foot and ankle literature. The goal of this article is to describe a method of correcting digital deformity utilizing the extensor digitorum brevis tendon transfer and a biotenodesis screw. The controlled tension established with the extensor tendon provides the necessary stability for multiplanar correction of multiplanar digital deformities. This technical tip article should serve as pilot study for future evaluation of this method of correction.

LEVELS OF EVIDENCE

Level IV: Case series.