Flexor to extensor tendon transfer for curly toes. 43 children reviewed after 8 (1-25) years

Assessment of the severity of curly toe

BACKGROUND

Curly/underlapping toe involves flexion, adduction, and varus deformity of the interphalangeal joints. There are no previous reports showing the relationship between physical examination and X-ray findings among patients with curly toe deformity.

METHODS

We investigated the clinical findings of 116 consecutive patients associated with 239 underlapping toes. We compared the age and affected toes between patients whose deformities were pointed out at a pediatric medical examination (group 1) and those referred for medical treatment (group 2). The degree of curly toe deformity was graded by a physical examination and X-ray.

RESULTS

The average age at presentation was 2.7 years. The affected toes were significantly different between groups 1 and 2 (p < .001). The morbidity of each toe differed significantly in group 2 (p < .005) but not in group 1. The correlation between the appearance grading and classification by X-ray was very strong using Spearman's rank correlation coefficient. The severity of curly toe was divided into mild in 104 toes, moderate in 105 toes, and severe in 17 toes. The methods of conservative treatment were observation only in 15 cases, manipulations in 30 cases, taping in 67 cases, and a brace in 9 cases. Surgery was performed in 8% of cases.

CONCLUSION

Curly toe deformity of the third or fourth toes tend to be referred for medical treatment because of the abnormality. Our grading system using a physical examination and classification by X-ray was useful for assessing the severity of curly toe.

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.

Pediatric Forefoot Deformities

This article explores different pediatric forefoot deformities including syndactyly, polydactyly, macrodactyly, curly toe, and congenital hallux varus. The epidemiology and genetic background are reviewed for each condition. Preferred treatment options and recommended surgical techniques are discussed with review of the current literature.

Minimally invasive correction for symptomatic, fixed curly toe deformity

BACKGROUND

Curly 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.

METHODS

Between 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.

RESULTS

The 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.

CONCLUSIONS

Minimally invasive dorsolateral closing wedge-shape osteotomy is a simple, safe, and effective correction for symptomatic, fixed curly toe deformity.

The efficacy of an extended scope physiotherapy clinic in paediatric orthopaedics

BACKGROUND

The demand for paediatric orthopaedic care is growing, and providing the service required is an increasingly challenging task. Physiotherapist-led triage clinics are utilised in adult orthopaedics to enable the provision of care to patients who may not require a surgical consult. The Physiotherapy Orthopaedic Triage Clinic (POTC) was established in Our Lady's Children's Hospital Crumlin in response to increasing demands on the paediatric orthopaedic service. The clinic is run by physiotherapists working in an advanced practice role (APP), and is the first paediatric clinic of its type and scale in the Republic of Ireland.

PURPOSE

To evaluate the efficacy of the service over the 3-year period from January 2011 to December 2013.

METHODS

A review of the prospectively gathered database was performed in order to establish the demographic profile of patients, investigate clinic outcomes, and evaluate the reduction in patient waiting times.

RESULTS

2650 patients were managed by the clinic over the 3-year period. A total of 77 % of patients were managed without consultant intervention. Fifty-three percent of patients were diagnosed as having a normal presentation. The mean waiting time reduced from 101.9 weeks pre-2010 to 15.4 weeks in 2013 for those patients managed by the POTC.

CONCLUSION

Since its inception, the clinic has significantly reduced waiting times for routine elective paediatric orthopaedic patients while managing the majority of patients independent of surgical opinion. This study shows that the APP can deliver high-quality care in the paediatric orthopaedic setting, benefitting both patients and service.

Fifth toe deformities: overlapping and underlapping toe

Overlapping fifth toe is thought to be a congenital deformity characterized by the proximal phalanx dorsally subluxating and adducting on the fifth metatarsophalangeal joint. Overlapping fifth toes may present as asymptomatic figments of parental concern, but not infrequently this deformity may be painful and disabling in both the pediatric and adult population. Pediatric overlapping fifth toe often corrects with normal ambulation and physicians only need to intervene if symptomatic deformity persists. Nonoperative optimization with strapping, splinting, and shoe modification would be reasonable first-line treatments. Surgical intervention including osteoclysis, percutaneous tenotomy, capsulotomy, syndacilization, tissue rearrangements, tendon transfers, phalangectomy, and toe amputation are indicated only after optimization of less invasive measures. Underlapping fifth toe (or "curly" toe) deformity is also felt to be congenital. In most cases, underlapping fifth toes are noticed by parents and family members early in infancy. The proximal phalanx in underlapping toes is typically in varus at the metatarsophalangeal joint with flexion. It is not uncommon for a rotational malalignment to be present (supination/pronation) as judged by the nailbeds. Similar to overlapping toes, pediatric underlappers commonly correct with reassurance and benign neglect up to age 6. Intervention is warranted in the setting of persistent pain and footwear difficulty. Accommodative shoes, absorbing cushions, and functional modification are the mainstays of nonoperative management. Operative intervention may consist of osteoclysis, percutaneous flexor tenotomy, capsulotomy, tissue rearrangements, tendon transfers, removal of symptomatic spurs, osteotomies, and amputation. After exhaustive review of the published literature, it is clear that fifth toe deformities (whether overlapping or underlapping) have not been extensively studied. No gold standard approach exists in treatment. Prospective research using larger numbers of patients with detailed outcome metrics are needed. Surgeons should carefully tailor surgical intervention to patient specific pathology.

LEVELS OF EVIDENCE

Expert Opinion, Level V.

Meta-analysis of flexor tendon transfer for the correction of lesser toe deformities

BACKGROUND

Transfer of the flexor digitorum longus tendon is one of the surgical techniques described to treat lesser toe deformities. A global analysis of the benefits of this procedure has not been presented in the literature to date. The aim of this meta-analysis was to evaluate the clinical benefit of transfer of the flexor digitorum longus tendon regarding patient satisfaction.

METHODS

A reviewer formally trained in meta-analysis abstraction techniques searched several databases to identify relevant published studies. Initially, 203 citations were identified and evaluated for relevance. Abstract screening produced 112 articles to be read in their entirety, of which 17 articles studying 515 procedures with a mean ± SD follow-up of 54.21 ± 20.64 months met all of the inclusion criteria necessary for analysis.

RESULTS

Overall crude patient satisfaction after flexor digitorum longus tendon transfer was 86.7% (95% confidence interval, 81.7%-90.5%). A low grade of heterogeneity across studies (Q = 24.458, I(2) =34.583, P = .080) and no influence of the individual studies on overall estimation were found. When adjusting for higher-quality prospective studies, overall patient satisfaction increased to 91.8%, although it did not reach statistical significance. Additional a priori sources of heterogeneity (age, sex, studies with <3 years of follow-up, percentage of patients lost to follow-up, and year of publication) were evaluated by subgroup analysis and meta-regression, but no statistical significance was found. This adjustment also significantly decreased heterogeneity across studies (crude Q = 24.458, high-quality studies Q = 1.504).

CONCLUSIONS

Regarding patient satisfaction, this comprehensive analysis provides supportive evidence of the clinical benefit of flexor digitorum longus tendon transfer.

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.

Modified Girdlestones-Taylor procedure for claw toes in spinal cord injury

STUDY DESIGN

A combination of review of case notes and outpatient follow-up.

OBJECTIVE

To evaluate the effectiveness of the modified Girdlestones-Taylor procedure in patients with spinal cord injury (SCI).

SETTING

Princess Royal Spinal Injuries Centre (PRSIC), Northern General Hospital, Sheffield, UK.

METHODS

Nine patients with claw toe deformities to 27 toes were treated at the PRSIC from 1996 to 2005. After examination of their medical records, their toes were assessed for pain, residual deformity and stiffness. They were also asked to grade their satisfaction with the surgical outcome. The results were tabulated.

RESULTS

The average age of our series of patients was 43.3 years. The mean time from injury to surgery was 20.4 years and the mean time from surgery to last follow-up was 37.3 months. All our patients had good to excellent results, with over 70% of the toes having excellent results.

CONCLUSION

The modified Girdlestones-Taylor procedure for claw toe correction appears to be a safe and effective treatment for patients with SCI.

A rare anomaly of the extensor digitorum longus

We encountered the absence of the tendon to the fourth toe of the extensor digitorum longus muscle of the right leg in the body of a 73-year-old Japanese woman during the course of educational dissection at Nagoya City University Medical School. The tendon to the fourth toe of the extensor digitorum longus muscle was solely absent. To our knowledge, this anatomical variation has never been cited in the medical literature. We document the precise gross anatomical findings with some morphometric measurements. Moreover, we discuss the morphology of this anomaly in relation to previously described variations and anomalies of the extensor digitorum longus muscle.

Congenital curly toe of the fetus

OBJECTIVES

To assess the prevalence, prenatal detection rate, and associated anomalies of congenital curly toe in an unselected obstetric population.

METHODS

Between September 2001 and July 2002, 1167 singleton fetuses in the second and third trimesters underwent routine prenatal ultrasound at our hospital. Congenital curly toe was diagnosed when the fourth or fifth toe was not fully delineated on the axial image with medial and plantar flexion on the coronal image. All neonates underwent a physical examination within 3 days after delivery. Radiography was performed on those infants with curly toe. We assessed the prevalence, prenatal detection rate, and associated anomalies of the condition.

RESULTS

There were 38 congenital curly toes among the 1167 neonates, yielding a total prevalence of 32.6 per 1000. In 26 of the 38 the fourth toe was curly and in 12 the fifth toe was curly. Of those in which the fourth toe was curly, 26.9% involved the right toe, 65.4% the left, and 7.7% involved both toes. For a curly fifth toe, these values were 25.0%, 16.7% and 58.3%, respectively. There was no associated structural anomaly, chromosomal abnormality, or syndrome in any case. Sixteen of the 38 curly toes were detected on prenatal ultrasound, including 13 of 26 with the fourth toe being curly and three of 12 with the fifth being curly.

CONCLUSIONS

Congenital curly toe is not an uncommon condition, and can be detected on the prenatal ultrasound. Although it usually appears as an isolated finding without clinical significance, thorough ultrasound examination of the fetus should be recommended.