Radiographic analysis of transverse plane digital alignment after surgical repair of the second metatarsophalangeal joint

How Important Is a Lesser Metatarsal Osteotomy in Preventing Second Hammertoe Recurrence?

Hammertoes with greater preoperative transverse plane deformity are more likely to recur after corrective surgery; however, it is unclear whether this represents an inherent (fixed, nonmodifiable) risk, or whether steps can be taken intraoperatively to mitigate this risk. In this study, we examined whether transverse plane transposition and/or shortening of the second metatarsal during second hammertoe surgery influenced recurrence. We performed a secondary analysis of pre-existing data from patients that had previously undergone second hammertoe surgery at our institution between January 1, 2011 and December 31, 2013. One hundred two patients (137 toes) were followed for a mean 28 ± 7.8 months postoperatively. Thirty-seven toes required, at the surgeon's discretion, an additional/concomitant Weil metatarsal osteotomy. Magnitude of transverse plane transposition and shortening of the second metatarsal, and joint angular measurements were obtained from the second metatarsophalangeal joint on weightbearing AP radiographs preoperatively and at 6 to 10 weeks postoperatively. Cox regression analysis was used to identify predictors of hammertoe recurrence using these new variables and a set of known predictors. In the final regression model, failure to establish a satisfactory postoperative metatarsal parabola (i.e., long second metatarsal; Nilsonne values <-4 mm, multivariate hazards ratio [HR] 1.96, p = .097), and intraoperative lateral transposition of the metatarsal head (multivariate HR 3.45, p = .028) seemed to confer additional risk for hammertoe recurrence. We conclude that shortening osteotomies may be assistive in some individuals, while further inquiry is still needed to determine whether similar benefits can be derived from medial head transposition in medial toe deformities.

The Reliability of Common Radiographic Measurements Used to Describe Foot Deformities

Radiographic measurements are frequently used to classify deformity and determine treatment options. Correlation coefficients can be used to determine inter- and intrarater reliability. Reliability is a required feature of any measurement if the measurement is to provide valid information. We calculated correlation coefficients for standard radiographic measurements used to categorize foot deformities: this was done for 52 sets of radiographs assessed by 5 raters. We aimed for generalizability, and kept rater instructions to match what was originally published for each measurement of interest with schematic illustration. Overall, our results mostly showed a lack of inter-rater reliability (correlation coefficients <0.4), and strong intrarater reliability (correlation coefficients >0.6), for 12 forefoot and 12 rearfoot radiographic measurements that are commonly used. The results of this investigation bring into question the routine use of radiographic measurements to categorize deformity, select treatments, and measure surgical outcomes, between surgeons, because the validity of these measurements appears to be threatened by weak inter-rater reliability. In order for these measurements to be considered useful, it may be necessary for surgeons to more rigorously define and practice making standard radiographic measurements.

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.

Lesser Metatarsophalangeal Joint Pathology Addressed With Arthrodesis: A Case Series

Lesser metatarsophalangeal joint pathology is a common condition facing the foot and ankle surgeon, often beginning as a mild subluxation of the toe and progressing to a full dislocation of the metatarsophalangeal joint. In severe or recalcitrant deformities, traditional conservative and surgical methods can fail to resolve the issue. We report on 4 patients with 5 severely dislocated lesser metatarsophalangeal joints with varied etiologies and comorbidities who underwent arthrodesis of these joints using screw and plate fixation. All patients achieved radiographic and clinical signs of union at an average of 16.4 weeks.

Bioabsorbable Fixation Screw for Proximal Interphalangeal Arthrodesis of Lesser Toe Deformities

BACKGROUND

Although standard fixation of proximal interphalangeal (PIP) arthrodesis by K-wire is relatively inexpensive and well established, it does have some drawbacks, making newer fixation devices interesting. The aim of this study was to clinically and radiologically assess the operative correction of the lesser toe deformation in the form of a PIP arthrodesis using a bioabsorbable 2.7-mm fixation screw.

METHODS

From January 2011 until October 2013, 34 patients underwent a PIP arthrodesis using the TRIM-IT (Arthrex) 2.7-mm fixation screw and were contacted for this retrospective cohort study. At an average of 3.3 years after the operation, 24 patients and 26 toes were evaluated clinically, radiologically, through pedobarography, and a patient-satisfaction survey.

RESULTS

Using the PLLA screw for fixation, 84.6% showed bony union of the arthrodesis, and 84.6% were satisfied. Mean AOFAS score was 82.7 points and thus regarded as good. The mean VAS score was 1.3/10. Overall, 73.1% of the toes showed good alignment, and 7.7% had a painless recurrence of deformity and were still satisfied with the intervention. In addition, 34.6% had floating toes, but only 4.2% without Weil osteotomy or encroachment. Further, 3.8% were advised to undergo a revision because of severe misalignment.

CONCLUSION

The 2.7-mm bioabsorbable fixation screw yielded results that were comparable to other fixation devices for PIP fusion fixation regarding success rate, revisions, and patient acceptance.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Dual-Component Intramedullary Implant Versus Kirschner Wire for Proximal Interphalangeal Joint Fusion: A Randomized Controlled Clinical Trial

We undertook a multicenter, parallel treatment arm, randomized controlled trial to compare the outcomes after surgery for the treatment of lesser digital hammertoe using either a Kirschner wire or a 2-piece intramedullary, stainless steel implant for fixation of the proximal interphalangeal joint. Our primary aim was to compare the incidence of arthrodesis and complications, and our secondary aim was to compare the subjective foot-related outcomes measured using the Bristol Foot Score and the Foot Function Index, stratified by fixation group. We hypothesized that the use of the dual-component implant would result in greater patient satisfaction, a greater incidence of radiographic arthrodesis, and fewer complications after hammertoe repair. The overall mean age of the participants was 58.72 ± 13.48 (range 18 to 84) years, their mean body mass index was 30.14 ± 6.55 (range 20.7 to 46.98) kg/m(2), and no statistically significant differences in the demographic variables were present between the treatment groups at baseline or during the follow-up period. Of the 91 participants, 46 (50.55%) were randomly allocated to the Kirschner wire group and 45 (49.45%) to the intramedullary implant group. No statistically significant differences were observed between the 2 fixation groups in the incidence of complications; however, the 2-piece intramedullary implant group was associated with a greater mean Bristol Foot Score and Foot Function Index score and a greater incidence of fusion.

Modification of the Weil/Maceira Metatarsal Osteotomy for Coronal Plane Malalignment During Crossover Toe Correction: Case Series

BACKGROUND

Metatarsophalangeal joint (MPJ) instability, which often involves the second ray, may result in dorsal translation and coronal drift of the proximal phalanx, with subsequent crossover of the first and second toe. After traditionally described soft tissue and osteotomy procedures are used to treat this deformity, coronal plane malalignment may persist, but few additional surgical options have been described to address this problem.

METHODS

We present a retrospective series of 5 patients who underwent a supplemental technique to augment coronal plane MPJ realignment. All patients underwent preplanned concomitant procedures. Crossover angulation of the second MPJ, amount of coronal translation required, and overall first-second ray alignment were compared pre- and postoperatively.

RESULTS

Depending on the severity of refractory deformity after soft tissue release and decompressive metatarsal osteotomy, 1.5 to 4.5 mm of coronal plane metatarsal head translation was required to achieve 3 to 20 degrees of overall valgus correction at the MPJ and complete correction of the crossover toe deformity. All patients were satisfied and had good function at last follow-up, a mean of 10.2 months, although 3 patients exhibited some level of second MPJ stiffness. One patient ended up with a component of residual floating toe deformity that was considered more of an incomplete correction of dorsal MPJ subluxation rather than any technical complication of this translational osteotomy modification designed to primarily correct coronal plane malalignment. A second patient had asymptomatic angular malalignment through partial (coronal plane) malrotation of the metatarsal osteotomy before it had healed.

CONCLUSIONS

We have found this technique modification to be a very effective and simple means of treating recalcitrant lesser MPJ coronal plane malalignment when traditional soft tissue and bony techniques fail to fully restore anatomic MPJ position.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Pinning across the metatarsophalangeal joint for hammertoe correction: where are we aiming and what is the damage to the metatarsal articular surface?

Kirschner wire (K-wire) fixation across the metatarsophalangeal joint (MTPJ) is commonly used in hammertoe repair surgery. The purpose of the present study was twofold: (1) to determine where the K-wire penetrates the metatarsal articular surface to achieve a rectus digit; and (2) to quantify the percentage of cartilage disruption to better understand the consequences of K-wire transfixation of the MTPJ. Arthrodesis was conducted on the second, third, and fourth proximal interphalangeal joints of 10 below-the-knee cadaver specimens, using a 1.6-mm K-wire. Digital alignment was confirmed with simulated weightbearing intraoperatively and radiographically. The K-wire was removed, and the MTPJ was dissected until the metatarsal head was fully exposed. The penetration point was plotted on a quadrant system with deviation noted from the epicenter. Center was defined as the point equidistant from the medial-to-lateral and superior-to-inferior edges on the distal surface of the metatarsal head, excluding the plantar condyles. Statistically significantly deviations were found in the K-wire placement from the center (35.9% ± 17.5%, p < .001), medial-to-lateral width (22.2% ± 19.2%, p < .001), and dorsal-to-plantar height (15.8% ± 25.0%, p = .002). Relative to the center, the K-wire was superior in 22 (79%), inferior in 6 (21%), medial in 22 (79%), and lateral in 6 (21%) of the cadaveric MTPJs. The mean percentage of disruption of the articular cartilage was 1.8% ± .4% and was similar for the second, third, and fourth MTPJs (p = .13) and for the left and right feet (p = .75). This information could be used to guide surgeons when they transfixate the MTPJ during hammertoe correction and might contribute to preservation of the articular cartilage.

A retrospective analysis of lesser metatarsophalangeal joint fusion as a treatment option for hammertoe pathology associated with metatarsophalangeal joint instability

Complex hammer digit deformity is commonly associated with instability of the metatarsophalangeal joint. Restoring joint stability is critical for digit alignment and function and can be challenging and unpredictable. Lesser metatarsophalangeal joint fusion might be an alternative treatment to the current soft tissue balancing, repair, and extra-articular osseous procedures used to treat joint instability. The present study was a retrospective chart and radiographic review of the pooled outcomes of 31 consecutive lesser metatarsophalangeal joint fusion procedures performed by 3 independent surgeons from May 2004 to September 2009. The clinical and radiographic outcomes were analyzed with descriptive and inferential statistics. The overall interval to radiographic union was 8.69 ± 1.7 weeks (range 6 to 12 and 95% confidence interval 7.9 to 9.4). The overall period to clinical union was 10.25 ± 4.5 weeks (range 4 to 22 and 95% confidence interval 8.5 to 11.9). The mean duration of non-weight-bearing was 4.71 ± 1.74 weeks, followed by 5.09 ± 2.8 weeks of guarded weight-bearing with a brace. Complications included nonunion in 4 (12.90%), hardware breakage in 2 (6.45%), and soft tissue infection in 1 (3.23%). Patients demonstrated a statistically significant reduction in pain (p = .035) and improved digit alignment after the procedure that enabled full return to unrestricted weight-bearing activities without limitations or the need for orthoses. These findings support metatarsophalangeal joint fusion as an alternative treatment of lesser digit metatarsophalangeal joint instability associated with hammer digit deformities that obviate the need for concomitant soft tissue procedures such as plantar plate repair or tendon balancing procedures.

Correction of crossover deformity of second toe by combined plantar plate tenodesis and extensor digitorum brevis transfer: a minimally invasive approach

PURPOSE

To study the efficacy and safety of the combined plantar plate tenodesis and extensor digitorum brevis transfer in correction of claw toe deformity.

METHODS

Between 2007 and 2008, 11 patients (13 feet) underwent combined plantar plate tenodesis and EDB transfer for the correction of crossover second toe deformity. The clinical and radiological results were studied.

RESULTS

There was no more crossover toe deformity in all patients. Two patients had residual mild residual claw toe deformity. The lateral metatarsophalangeal angle in preoperative weight-bearing radiograph averaged 53° ± 5°. The postoperative lateral metatarsophalangeal angle averaged 23° ± 6°. The dorsoplantar metatarsophalangeal angle in preoperative weight-bearing radiograph averaged -9° ± 4°. The postoperative dorsoplantar metatarsophalangeal angle averaged 2° ± 4°.

CONCLUSIONS

Combined plantar plate tenodesis and extensor digitorum brevis transfer is an effective procedure to correct crossover second toe deformity. This is a relatively simple procedure and can be preformed through small incisions with minimal soft tissue dissection.

LEVEL OF EVIDENCE

Level 3 therapeutic study.

The translating Weil osteotomy in the treatment of an overriding second toe: a report of 25 cases

We present a retrospective study of 25 feet operated for an overriding second toe deformity, whether or not associated with hallux valgus deformity and metatarsalgia. The surgical technique of a medial sliding and decompressive Weil osteotomy is described. All patients, operated between January 2002 and December 2007 for this condition in our institution, were reviewed clinically and radiologically. The mean AOFAS score improved with 47.6 points from 45.9 to 93.5. The theoretical advantages of such a translation Weil osteotomy are discussed trying to clarify the previously described pathologic anatomy of this condition.

[Subligamentous transfer of the extensor digitorum brevis tendon for medial malalignment of the lesser toes]

OBJECTIVE

Realignment of medially deviated lesser toes II-IV via subligamentous transfer of the extensor digitorum brevis tendon to treat painful toe disorders.

INDICATIONS

Flexible medial malalignment of the lesser toes II-IV attributed to transverse instability of the metatarsophalangeal joint.

CONTRAINDICATIONS

Contract lesser toe deformities. Medial malalignment due to an osseous pathology or instability of the proximal interphalangeal joint. Neuropathy. Infection.

SURGICAL TECHNIQUE

Regional anesthesia. Patient in supine position. Dorsal S-shaped skin incision at the metatarsophalangeal joint. Medial split of the extensor hood. Dorsomedial capsular release. Distal tenotomy of the extensor digitorum brevis tendon. Transfer of the tendon slip beneath the intermetatarsal ligament to the lateral aspect of the proximal phalanx. After manual realignment of the toe periosteal or intraosseous fixation of the tendon.

POSTOPERATIVE MANAGEMENT

Bulky dressing with well-aligned toes. Anti-inflammatory drugs. Walking (full weight bearing) with a forefoot relief orthosis for 4 weeks. Toe splint and/or bandage for 12 weeks. Active exercises (toe flexion, standing on tiptoes, aquajogging) can be started after 4 weeks. Comfortable shoeware after 4 weeks.

RESULTS

23 of 32 patients with flexible medial malalignment of the lesser toes II and/or III were followed up after a mean of 19 months. Medial malalignment could be reduced markedly (preoperatively 28 degrees, postoperatively 6 degrees). Four patients treated with the tendon transfer alone developed a recurrent deformity with dorsal subluxation at the metatarsophalangeal joint level. These patients revealed a concomitant hallux valgus deformity of >30 degrees. Six patients with an additional metatarsal shortening presented with floating toes. Although all patients were able to stand on tiptoes, the active range of toe motion was decreased. Radiologically, joint congruency was improved. 18 patients revealed a congruent joint, and five patients presented with a medial subluxation of the proximal phalanx.