Transfer of the flexor digitorum longus for the correction of lesser-toe deformities

Influence of the biomechanical evaluation of rupture using two shapes of same intramedullary implant after proximal interphalangeal joint arthrodesis to correct the claw/hammer pathology: A finite element study

We used finite element analysis to study the mechanical stress distribution of a new intramedullary implant used for proximal interphalangeal joint (PIPJ) arthrodesis (PIPJA) to surgically correct the claw-hammer toe deformity that affects 20% of the population. After geometric reconstruction of the foot skeleton from claw toe images of a 36-year-old male patient, two implants were positioned, in the virtual model, one neutral implant (NI) and another one 10° angled (10°AI) within the PIPJ of the second through fourth HT during the toe-off phase of gait and results were compared to those derived for the non-surgical foot (NSF). A PIPJA was performed on the second toe using a NI reduced tensile stress at the proximal phalanx (PP) (45.83 MPa) compared to the NSF (59.44 MPa; p < 0.001). When using the 10°AI, the tensile stress was much higher at PP and middle phalanges (MP) of the same toe, measuring 147.58 and 160.58 MPa, respectively, versus 59.44 and 74.95 MPa at corresponding joints in the NSF (all p < 0.001). Similar results were found for compressive stresses. The NI reduced compressive stress at the second PP (-65.12 MPa) compared to the NSF (-113.23 MPa) and the 10°AI (-142 MPa) (all p < 0.001). The von Mises stresses within the implant were also significantly lower when using NI versus 10°AI (p < 0.001). Therefore, we do not recommend performing a PIPJA using the 10°AI due to the increase in stress concentration primarily at the second PP and MP, which could promote implant breakage.

Treatment of Dynamic Claw Toe Deformity Through Lengthening of the Flexor Tendons of the Hallux and Toes at the Midfoot Level

The claw toe deformity is characterized by the flexion of interphalangeal joints (IPJs) with hyperextension of the metatarsophalangeal (MTP) joint. It can be flexible and reducible or rigid and irreducible, or dynamic. The most common cause of dynamic claw toes is a neurological disorder, like sequelae of an ischemic contracture of the muscle belly after a compartment syndrome. Most of the surgical techniques require multiple procedures and may be associated with complications such as toe stiffness, persisting metatarsalgia, and toe malalignment. The aim of this study is to present an option for the surgical treatment of the dynamic claw toe deformity, by simultaneous tenodesis and lengthening of the flexor hallucis longus (FHL) and flexor digitorum longus (FDL) tendons at Henry's knot through a single midfoot incision.Levels of Evidence: V; Therapeutic Study; Expert Opinion.

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.

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.

Impact of intertendinous connections between the flexor digitorum brevis and longus on percutaneous tenotomy for the treatment of claw toes: an anatomic and ultrasound study

PURPOSE

Selective percutaneous tenotomy of the flexor digitorum longus (FDL) is a treatment for claw toes that gives astonishingly good functional results despite tendon sacrifice. However, the involution of the FDL tendon stump after tenotomy is unknown. The aim of our study was to assess the involution of the tendon stump after selective percutaneous tenotomy of the FDL.

METHODS

The study included two parts. In the clinical part, an ultrasound analysis of 15 FDL tenotomies in 7 patients was carried out 3 months post-surgery. In the anatomic part, the feet of 10 bodies donated to science were dissected and examined anatomically.

RESULTS

The proximal stump of the FDL was located near the base of the proximal phalanx and moved synchronously with the flexor digitorum brevis (FDB).Separating the FDB and FDL revealed a large tissue connection between the plantar surface of the tendinous chiasm of the FDB and the dorsal part of the FDL. These connections had significant resistance ranging from 2 to 9 Newtons depending on the toe. Tenotomy of the FDL followed by proximal traction of it led to retraction of the stump up to the base of the proximal phalanx and transfer of its action to the FDB by tensioning the intertendinous structure. Histologically, these structures were mostly comprised of tendon connective tissue. Their vascular component was small.

CONCLUSION

The presence of this intertendinous connection leads, in the case of isolated tenotomy of the FDL, to equivalent transfer of the latter to the FDB.

Intramedular transfer of the flexor digitorum brevis tendon for the correction of clawtoe/hammertoe deformity: A cross-sectional study

BACKGROUND

A literature review did not reveal any studies concerning the intramedullary transfer of the flexor digitorum brevis tendons (FDB) technique with a single longitudinal incision through the proximal phalanx of the toes. The main goal of this investigation was to demonstrate whether the FDB tendons of the toes are long enough to enable intramedullary transfer to the dorsal area of the proximal phalanx.

METHODS

We examined whether the technique would allow the surgeon to transfer the FDB tendons through the proximal phalanx of the toes. The technique transfers the FDB tendons through the proximal phalanx dorsal area of the toes using an intramedullary transfer of the FDB tendons. The intramedullary transfer of the FDB tendons was performed through a single dorsal incision.

RESULTS

The FDB tendons for the second, third, and fourth toes were performed in 100% of the feet. No ruptures in any toe in which the surgical technique was performed was noted, and no proximal phalanges of the second, third, and fourth toes were fractured.

CONCLUSIONS

Transfer of FDB tendons via the intramedullary approach of the proximal phalanx of the second, third, and fourth toes is possible. The FDB tendons have sufficient length for transfer via an intramedullary transfer and were carried out in 100% of the second toes. For a successful transfer, it is essential to perform a thorough resection of the extensor digitorum longus aponeurosis since it has expansions intimately attached to the plantar base of the proximal phalanx of the toe.

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.

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.

Tendon Transfers for Management of Digital and Lesser Metatarsophalangeal Joint Deformities

Managing digital and metatarsophalangeal joint (MTPJ) deformities can range from simple to complex and uniplanar to triplanar. Because of the complexity and variability of digital and MTPJ deformities, there are many procedures, and no 1 procedure has become the gold standard. Tendon transfers for digital and MTPJ deformities are just 1 treatment option, and usually they are not stand-alone procedures. Typically, a combination of procedures needs to be performed. This article describes the surgical technique and provides a review of the literature, including clinical results for tendon transfers of the central rays.

Reduction of Dorsal Displacement of the Proximal and Middle Phalanges Using a Neutral or Angled Implant for Joint Arthrodesis to Treat Hammertoe Deformity A Finite Element Study

BACKGROUND

We used finite element analysis to study the mechanical displacements at three planes of the second through fourth hammertoes during the push-off phase of gait using a new neutral or 10° angled memory alloy intramedullary implant (FDA K070598) used for proximal interphalangeal joint arthrodesis.

METHODS

After geometric reconstruction of the foot skeleton from computed tomographic images of a 36-year-old man, an intramedullary implant was positioned in the virtual model at the neutral and 10° angled positions at the proximal interphalangeal joints of the second through fourth hammertoes during the push-off phase of gait. The obtained displacement results in three planes were compared with those derived from the nonsurgical foot model using finite element analysis.

RESULTS

These results support the successful use of either a neutral or angled implant for proximal interphalangeal joint arthrodesis, with the neutral implant yielding slightly better results.

CONCLUSIONS

The neutral implant reduced vertical displacement to a greater extent than did the angled implant. We also highlight the potential risk of iatrogenic curly toe when performing a proximal interphalangeal joint arthrodesis using an angled implant specifically at the fourth toe.

Percutaneous correction of second toe proximal deformity: Proximal interphalangeal release, flexor digitorum brevis tenotomy and proximal phalanx osteotomy

We report the results of a percutaneous technique to correct a proximal plantar flexion deformity of the second toe that combines several procedures: tenotomy of the Flexor Digitorum Brevis, plantar capsulotomy for release of the proximal interphalangeal joint and proximal phalangeal osteotomy. The goal of these procedures is to improve anatomical correction and preserve articular range of motion. From 2009 to 2011, 54 patients, mean age 64.4 years old (43-81) underwent surgery for a proximal deformity of the second toe. Associated tenotomy of the extensor digitorum longus and brevis was performed in the presence of an extension deformity of the metatarsophalangeal joint (24 cases). After a mean follow-up of 30.7 ± 8.9 months, the rate of satisfaction and morphological correction was high (89.5% in both cases), as well as the number of flexible toes (88%). Active plantar flexion was preserved in 86% of the cases. This seems to be an effective technique to correct proximal plantar flexion deformity of the second toe, while preserving active plantar flexion.

Single longitudinal dorsal incision approach to transfer the flexor digitorum longus tendon between the flexor digitorum brevis hemitendons: a cadaveric study

Transposition of the flexor digitorum longus tendon has been widely reported for the correction of flexible claw and hammertoe deformities. The most common technique uses two cutaneous incisions, one plantar and another dorsal. We performed a cadaveric study to determine whether the flexor digitorum longus tendon could be transferred to the dorsum of the proximal phalanx of the toe from its lateral or medial aspect through a unique single longitudinal central dorsal incision. The rationale for this novel approach was to minimize the risk of vascular compromise to the digit associated with the two-incision approach. Transposition of the flexor digitorum longus tendon was attempted in 120 toes of cadaveric feet (60 each second and third digits) through a central longitudinal dorsal incision. The flexor digitorum longus tendon segment was long enough to be successfully transposed between the flexor digitorum brevis hemitendons of the second and third toes in 100% of the cases using the central longitudinal dorsal incision approach, with a resection arthroplasty at the proximal interphalangeal joint. Transfer of the flexor digitorum longus tendon to the dorsum of the proximal phalanx can be performed for the correction of claw and hammertoe deformities in the second and third digits. The meticulous longitudinal incision of the flexor tendon sheath to expose the flexor digitorum brevis tendon and its longitudinal incision are essential to the successful transfer of the flexor digitorum longus tendon between the flexor digitorum brevis hemitendons.

Stress at the second metatarsal bone after correction of hammertoe and claw toe deformity: a finite element analysis using an anatomical model

BACKGROUND

We used finite element analysis to evaluate three techniques for the correction of hammertoe and claw toe deformities: flexor digitorum longus tendon transfer (FDLT), flexor digitorum brevis tendon transfer (FDBT), and proximal interphalangeal joint arthrodesis (PIPJA).

METHODS

We performed a finite element analysis of FDLT and FDBT compared with PIPJA of the second toe using multislice computed tomography and 93 tomographic images of the foot obtained in a healthy 36-year-old man.

RESULTS

The PIPJA showed a significantly higher increase in traction and compressive stresses and strain at the medial aspect of the shaft of the second metatarsal bone compared with FDLT or FDBT (P < .01). Mean ± SD compressive stresses increased to -4.35 ± 7.05 MPa compared with the nonsurgical foot (-3.10 ± 4.90 MPa). It can, therefore, be hypothesized that if PIPJA is used to correct the hammertoe and claw toe deformities, it could also increase traction and compressive stresses and strain in the metatarsals during running and other vigorous activities.

CONCLUSIONS

There is a biomechanical advantage to performing FDLT or FDBT instead of PIPJA to surgically treat a hammertoe or claw toe deformity. In addition, tensile strain at the dorsal aspect of the second metatarsal bone when performing PIPJA increases the risk of metatarsalgia or stress fracture in patients at risk.

Forefoot tendon transfers

Flexible forefoot deformities, such as hallux varus, clawed hallux, hammer toes, and angular lesser toe deformities, can be treated effectively with tendon transfers. Based on the presentation of the flexible forefoot deformities, tendon transfers can be used as the primary treatment or as adjuncts to bony procedures when there are components of fixed deformities.

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.

Treatment of dynamic claw toe deformity flexor digitorum brevis tendon transfer to interosseous and lumbrical muscles: a literature survey

The authors report the results of a literature survey of corrective surgical treatment based on FDL and FDB tendon transfer for dynamic claw toe deformities. The study revealed that FDL transfer was first described in 1967 by Malcolm A. Brahms in "Common Foot Problems", and FDB transfer was first mentioned in 1993 in the first edition of the treatise by G. Pisani "Trattato di Chirurgia del Piede". The paper also discusses the functional effect of FDB transfer, compared to FDL transfer.

Role of collateral ligaments in metatarsophalangeal stability: a cadaver study

BACKGROUND

Lesser metatarsophalangeal joint (MTPJ) instability is a common complaint. The role each of the collateral structures play in maintaining joint stability is unknown.

METHODS

Twenty-six fresh-frozen cadaver lesser MTPJ's were tested for instability with the amount of force necessary to translate the joint 3 mm dorsally. Specimens were tested with 1) intact collateral ligaments, 2) transected accessory collateral or proper collateral ligaments (ACL or PCL), 3) repaired ACL or PCL, 4) transected ACL and PCL, 5) repaired ACL and PCL, and 6) transferred interosseous (IO) tendon. Student t-tests were performed to test for statistical significance (p value less than 0.05).

RESULTS

The mean force required for 3 mm of dorsal displacement was 25 ± 13 N (range, 11 to 52 N) in the 26 specimens. Transecting either the ACL alone or the ACL and PCL led to the most instability versus transecting the PCL alone. Repairing both ligaments improved stability. The IO tendon transfer was comparable to the direct repair of the PCL but was inferior to the direct repair of the ACL.

CONCLUSION

Both ACL and PCL have a stabilizing effect on the MTPJ. However, the ACL was more important since primary transection of the ACL led to more instability and additional transection of the PCL in an ACL deficient model did not lead to significantly more instability.

CLINICAL RELEVANCE

Direct repairs of both structures improved the stability of the joint but not back to normal. IO tendon transfer is a possible adjunct to collateral ligament repairs, but in itself is not sufficient to restore stability.

Dorsal approach to transfer of the flexor digitorum brevis tendon

BACKGROUND

Transposition of the flexor digitorum longus tendon has been widely reported for the correction of flexible claw and hammer toe deformities. Only transposition of the flexor digitorum brevis tendon has been reported in the literature in a cadaveric study that used the dorsal and plantar approach. A search of the literature revealed no reports of transposition of the flexor digitorum brevis tendon for treatment of these conditions through a unique dorsal cutaneous incision. We performed a cadaveric study to determine whether the flexor digitorum brevis tendon is long enough to be transferred to the dorsum of the proximal phalanx of the toe from its lateral or medial aspect through a unique dorsal cutaneous incision.

METHODS

Transposition of the flexor digitorum brevis tendon was attempted in 156 toes of cadaveric feet (52 each second, third, and fourth toes) through a unique dorsal incision.

RESULTS

The flexor digitorum brevis tendon was long enough to be successfully transposed in 100% of the second, third, and fourth toes by the dorsal incision approach.

CONCLUSIONS

Transfer of the flexor digitorum brevis tendon to the dorsum of the proximal phalanx can be performed for the correction of claw and hammer toe deformities, especially in the second, third, and fourth toes. The meticulous longitudinal incision of the flexor tendon sheath to expose the flexor digitorum brevis tendon is essential to the success of the procedure.

Hammertoes/Clawtoes: metatarsophalangeal joint correction

Clawing of the lesser toes is not uncommon, can arise from a number of causes, and is often associated with other forefoot abnormalities. There is still some confusion in the nomenclature of lesser toe deformities affecting the MTPJ and PIPJ although the resulting deformities are probably part of the same pathologic process and thus treated in a similar manner. Many will be successfully treated with nonoperative methods, but if they fail a number of surgical options are available depending on the severity of the deformity and whether the deformity is fixed or flexible. Correction at the MTPJ can be achieved using a stepwise progression of soft-tissue procedures alone, bony procedures, or a combination of both.

The use of flexor to extensor transfers for the correction of the flexible hammer toe deformity

Flexor to extensor transfer is a useful means for the correction of a flexible hammer toe deformity. Although satisfaction rates have varied in the literature, this technique remains a useful tool in the surgeon’s armamentarium to improve toe deformity, decrease pain, and aid in shoe wear.

Lesser toe deformities

Lesser toe deformities are caused by alterations in normal anatomy that create an imbalance between the intrinsic and extrinsic muscles. Causes include improper shoe wear, trauma, genetics, inflammatory arthritis, and neuromuscular and metabolic diseases. Typical deformities include mallet toe, hammer toe, claw toe, curly toe, and crossover toe. Abnormalities associated with the metatarsophalangeal (MTP) joints include hallux valgus of the first MTP joint and instability of the lesser MTP joints, especially the second toe. Midfoot and hindfoot deformities (eg, cavus foot, varus hindfoot, valgus hindfoot with forefoot pronation) may be present, as well. Nonsurgical management focuses on relieving pressure and correcting deformity with various appliances. Surgical management is reserved for patients who fail nonsurgical treatment. Options include soft-tissue correction (eg, tendon transfer) as well as bony procedures (eg, joint resection, fusion, metatarsal shortening), or a combination of techniques.

Digital surgery: current trends and techniques

Digital deformities continue to be a common ailment among many patients who present to foot and ankle specialists. When conservative treatment fails to eliminate patient complaints, surgical correction remains a viable treatment option. Proximal interphalangeal joint arthrodesis remains the standard procedure among most foot and ankle surgeons. With continued advances in fixation technology and techniques, surgeons continue to have better options for the achievement of excellent digital surgery outcomes. This article reviews current trends in fixation of digital deformities while highlighting pertinent aspects of the physical examination, radiographic examination, and surgical technique.

Modified plantar plate tenodesis for correction of claw toe deformity

BACKGROUND

The purpose of the study was to evaluate the efficacy and safety of the modified plantar plate tenodesis for correction of claw toe deformity.

MATERIALS AND METHODS

Modified plantar plate tenodesis was performed in ten fresh frozen cadaveric feet with claw toe deformity of the second toe. The plantar plate of the second metatarsophalangeal joint was anchored to the extensor digitorum longus tendon by a figure-of-eight suture. The figure-of-eight construct and the relationship of the digital nerve and the suture were studied. A clinical study was conducted to study the operative times, degree of correction and the improvement of AOFAS score between groups with the original plantar plate tenodesis (Group 1) and modified technique (Group 2). Any neural injury if present was also noted.

RESULT

In the cadaveric study, the claw toe deformity was corrected and no nerve injury occurred in any specimen. There was flexor tendon tethering by the suture in 2 specimens. In the clinical study, the average operative time was 51 minutes for Group 1 and 31 minutes for Group 2. The improvement in AOFAS score averaged 44 in Group 1 and 43 in Group 2. The corrective power of the sagittal plane deformity at the metatarsophalangeal joint averaged 25 degrees in Group 1 and 23 degrees in Group 2.

CONCLUSION

Plantar plate tenodesis was effective in correction of flexible claw second toe deformity by stabilization of the attenuated plantar plate. The modified technique allowed easier retrieval of the suture and shorter operative time. However, it may result in tethering of the flexor tendon.

Advantages and Drawbacks of Proximal Interphalangeal Joint Fusion Versus Flexor Tendon Transfer in the Correction of Hammer and Claw Toe Deformity. A Finite-Element Study

Correction of claw or hammer toe deformity can be achieved using various techniques, including proximal interphalangeal joint arthrodesis (PIPJA), flexor digitorum longus tendon transfer (FDLT), and flexor digitorum brevis transfer. PIPJA is the oldest technique, but is associated with significant complications (infection, fracture, delayed union, and nonunion). FDLT eliminates the deformity, but leads to loss of stability during gait. Flexor digitorum brevis tendon transfer (FDBT) seems to be the best surgical alternative, but it is a recent technique with still limited results. In this work, these three techniques have been analyzed by means of the finite-element method and a comparative analysis was done with the aim of extracting advantages and drawbacks. The results show that the best technique for reducing dorsal displacement of the proximal phalanx is PIPJA (2.28 mm versus 2.73 mm for FDLT, and 3.31 mm for FDBT). However, the best technique for reducing stresses on phalanges is FDLT or FDBT (a reduction of approximately 35% regarding the pathologic case versus the increase of 7% for the PIPJA in tensile stresses, and a reduction of approximately 40% versus 25% for the PIPJA in compression stresses). Moreover, the distribution of stresses in the entire phalanx is different for the PIPJA case. These facts could cause problems for patients, in particular, those with pain in the surgical toe.

Digital fracture after a flexor tendon transfer for hammertoe repair: a case report

The authors present a case report of a complication of a complete phalangeal fracture after flexor digitorum longus tendon transfer used for the surgical correction of a hammertoe deformity.

Clinical outcome after percutaneous flexor tenotomy in forefoot surgery

The aim of this study was to evaluate the outcome of the percutaneous flexor tenotomy. We compared the results of two groups. The first group included 23 patients who underwent forefoot surgery without percutaneous flexor tenotomy, and the second group included 50 patients who underwent the same procedure combined with percutaneous flexor tenotomy for claw toe deformities, secondary to shortening metatarsal Scarf osteotomy. The average follow-up was 11.6 months. Three algoneurodystrophies were noted. No delayed wound healing was observed. Functional dissatisfaction rate (18% vs.17.4%) and toe pulp contact defect (12% vs. 8.7%) were not significantly different in the two groups. Toe grasping defect rate (10% vs. 4.3%) was superior in the tenotomy group. Five recurring claw toe deformities of the second toe were noted in the tenotomy group. Percutaneous flexor tenotomy is a simple, rapid, and efficient method to correct reducible secondary claw toe deformities. However, despite a significant postoperative loss of toe grasping function, no patient reported major dissatisfaction.