Revision surgery of the lesser toes

Midterm severe forefoot deformity treatment outcomes in elderly patients

Severe complex deformities of the forefoot in elderly patients with no rheumatoid arthritis result in the pronounced decrease in quality of life, chronic pain, reduced mobility, failure to get shoes for everyday use, exacerbation of the concomitant somatic diseases. The use of conventional joint preservation techniques in such patients often leads to the deformity relapse, persistent pain, and the need for revision surgery that is often impossible due to worsening of the patients' general somatic status and local functional status. The study was aimed to improve surgical outcomes in elderly patients with no rheumatoid arthritis who had severe forefoot deformities. The prospective cohort study that involved allocation to the retrospective group for comparison of surgical outcomes in 65 patients was carried out in 2016–2019. The results obtained before and after surgery were assessed using the FFI, AOFAS Hallux, and AOFAS Lesser Toes scores. The Maryland scores were used to assess the outcomes during the postoperative period. The study revealed significant differences in treatment outcomes based on the AOFAS Hallux (p = 0.0001), AOFAS Lesser Toes (p = 0.0001), FFI (p = 0.0001), and Maryland (p = 0.0001) scores. In view of the elderly patients' specific nature, the radical surgical techniques that do not ensure joint preservation may be considered as effective and predictable methods of correction aimed at reducing the rate of revision surgeries. These techniques represent a one-step method to improve the quality of life of elderly patients.

Pediatric Hammertoe Recurrence-Considerations for Revision Surgical Technique and Hypoperfusion Management: A Case Report

CASE

A 7-year-old girl presented with a recurrent hammertoe deformity causing pain with shoe wearing after a prior corrective surgery. Surgical revision required a unique approach that included a staged corrective osteotomy of the proximal phalanx because of hypoperfusion management and the application of a rotational skin flap previously described for camptodactyly correction in the hand to avoid harvesting a skin graft.

CONCLUSION

Revision surgery for recurrent pediatric hammertoe deformity requires a heightened awareness of the risk for toe hypoperfusion and subsequent wound closure challenges.

Effectiveness of minimally invasive surgery using incomplete phalangeal osteotomy for symptomatic curly toe of adults with a trapezoidal phalanx: An observational study

Background and aims

Digital deformity in flexion, varismus (external rotation), and adduction with the toe in both supraduction and infraduction are called clinocampodactyly or curly toe. All adult patients with symptoms and a diagnosis of semirigid/rigid curly toes underwent radiological examination to verify the presence of a trapezoidal phalanx. The purpose of this study was to quantitatively determine the degrees of improvement of a dysmetric phalanx after incomplete phalangeal osteotomy using minimally invasive surgery. The points of improvement were determined using the American Orthopedic Foot and Ankle Society (AOFAS) scale score.

Methods

Between May 2021 and June 2022, 30 patients diagnosed with curly toes underwent unicortical osteotomy of the affected phalanx. The convergence angle was measured and the AOFAS scale scores were compared.

Results

A total of 33 toes underwent surgery. The average reduction of the convergence angle was 9°. The average improvement in the AOFAS scale score was 53 points at 6 months and reached almost 90 points (89.9 ± 6.1 points).

Conclusions

Incomplete phalangeal osteotomy performed with minimally invasive surgery of the trapezoidal phalanges of curly toes of adults can improve alignment and AOFAS scale scores.

Complications of Lesser Toe Surgery: How To Avoid Them before Surgery and How To Assess and Treat Them When They Have Occurred

Complications following lesser toe surgery are challenging to manage. The keys to treatment of any of these conditions are, first, to try to avoid them through identification of patient- and surgeon-related variables that contribute to their development and, second, following the occurance of a complication, to understand what can and cannot be corrected with surgical and nonsurgical management. This review provides a comprehensive assessment of current literature, demonstrates best practices and approaches to lesser toe complications, and provides an illustration of clinical examples.

Flexor tenodesis procedure in the treatment of lesser toe deformities

In this technical report study, we describe the use of a flexor tenodesis procedure in the treatment of lesser toe deformities (LTD). Using a specific implant, both the flexor digitorum longus and brevis tendons are attached to the plantar aspect of the proximal phalanx, allowing dynamic correction of flexible deformities of metatarsophalangeal and interphalangeal joints. Good clinical results and absence of complications were observed in a series of 3 patients, with considerable correction of the LTD, and absence of substantial residual floating toe or metatarsophalangeal joint stiffness. LEVEL OF EVIDENCE: V - Technical Report/Case Report/Expert Opinion.

The Ischemic toe following forefoot surgery: A review of current practices and a proposed approach for management

Toe hypoperfusion is a commonly encountered concern following forefoot surgery, yet there is limited clinical guidance available to surgeons to aid in management of this scenario. This work aims to review the etiology, pathophysiology and current strategies to address a perioperative ischemic toe. The authors review various interventions to approach this problem based on available evidence and clinical experience. Interventions to restore perfusion can be loosely based on the ischemic causality they intend to address. Described maneuvers to restore perfusion have, in turn, been designed to either chemically (through topical/local medication) or mechanically (bending/removing K-wires, adjusting repair tension) aid in mitigation of the offending cause. Depending upon the type of surgery performed, which may or may not include instrumentation, a surgeon can implement a series of steps to maximize restoration of toe perfusion. LEVEL OF EVIDENCE: V.

Ischemic toe after surgery for lesser toe deformities: An algorithm

Ischemia after correction of lesser toe deformities is usually due to temporary vasospasm and can rarely cause gangrene. The published literature on dealing with the issue and been reviewed and used to suggest an algorithm for a logical step by step approach to a pale or white toe when encountered in the postoperative period.

The Role of Lesser Metatarsophalangeal Joint Arthrodesis for Revision Surgery

Revision hammertoe surgery can be extremely challenging for the foot and ankle surgeon given the scar tissue and available osseous and soft tissue. Although not a common procedure, lesser metatarsophalangeal joint arthrodesis is an option for the patient especially in lieu of an amputation. This article describes the current literature and the surgical technique for a lesser metatarsophalangeal joint arthrodesis.

Managing Complications of Lesser Toe and Metatarsophalangeal Joint Surgery

The anatomy of the lesser toes is highly complicated and not yet well understood. The high propensity of the metatarsophalangeal joint to develop hyperextension deformity should be recognized. Surgeons should provide each patient with a realistic expectation for lesser toe reconstructive procedures. A successful surgical result requires a well-planned procedure, accurate execution using proper techniques, and meticulous postoperative care. When complications occur, surgeons should identify culprits so that proper treatment strategies can be successfully executed. This article discusses a wide array of tactics to manage common complications in lesser toe surgery.

Extensor apparatus of the lesser toes: anatomy with clinical implications--topical review

Lesser toe deformities are one of the most common conditions faced by orthopedic surgeons. Knowledge of the anatomy of the lesser toes is important for ensuring correct diagnosis and treatment of deformities, which are caused by factors such as muscle imbalance between the extensor apparatus and flexor tendons. However, this apparatus has not received sufficient attention in the literature. In addition, the large number of inaccurate and erroneous descriptions means that gaining an understanding of these structures is problematic. The objective of the present article is to clarify the anatomy of the extensor apparatus by means of a pictorial essay, in which the structures involved will be grouped and discussed in detail. The most relevant clinical implications will be addressed.

LEVEL OF EVIDENCE

Level V, expert opinion.