Vascularized Origami Medial Femoral Condyle Flap for Finger Joint Reconstruction

SUMMARY

Total finger joint reconstruction is challenging. Vascularized toe joint transfer is currently used for reconstruction, but it is difficult to perform, fails to achieve maximal joint flexibility, and is associated with donor-site complications. As an alternative, the authors developed a vascularized medial femoral condyle flap technique, wherein the vascularized corticoperiosteum is shaped via origami, with the donor tissue folded to fit the recipient site. In this article, the authors describe the use of this method for reconstruction of interphalangeal and metacarpophalangeal joints with a reduced range of motion. The mean age of the patients (three men and four women) was 51 years (range, 36 to 68 years), and the mean follow-up period was 3 years 1 month (range, 4 months to 5 years). In the reconstructed joints, the mean range of motion; Disabilities of the Arm, Shoulder, and Hand score; and pinch strength of the unaffected side were 55 degrees (range, 24 to 90 degrees), 2.3 (range, 0 to 6), and 98% (range, 70% to 38%), respectively. No donor-site morbidities were observed. Radiography and computed tomography scans revealed joint-like grafted tissue remodeling. The study findings suggest that the origami medial femoral condyle flap is useful for functional finger joint reconstruction. The procedure requires fabrication before grafting, but tissue harvest is relatively easy.

Minimally Invasive Arthrodesis of the Equine Proximal Interphalangeal Joint: A Biomechanical Comparison of Three 5.5-mm Cortical Screws Inserted in Lag Fashion and Two 7.0-mm Headless Cannulated Dual-Pitch Compression Screws

OBJECTIVE

 The aim of this study was to compare the biomechanical properties of two minimally invasive arthrodesis techniques of the equine proximal interphalangeal (PIP) joint (three transarticular 5.5-mm cortical screws [AO-3TLS] vs. two transarticular 7.0-mm headless cannulated multi-use compression screws [MUC-2TS]) in dynamic non-destructive testing and compression testing to failure.

STUDY DESIGN

 The experimental study included six pairs of cadaveric adult equine forelimbs; one limb from each horse was randomly assigned to one of the treatments, and the contralateral limb was submitted to the remaining treatment. The dynamic test was performed alternating non-destructive compression tests at a displacement rate of 5 mm/min up to 5,000 N and sinusoidal compressive cyclic tests at 6 Hz, using a 3,600-N amplitude for 8,550 cycles. Construct stiffness and maximum sagittal plane rotation about the PIP joint markers were determined during the dynamic test. After the dynamic test reached 136,800 cycles, the monotonic compressive test until failure was performed on each construct: load, displacement and sagittal plane rotation about the PIP joint marker at failure were analysed.

RESULTS

 The evaluated biomechanical properties showed no statistical difference between the AO-3TLS and MUC-2TS treatment groups in any of the ramps of the dynamic non-destructive test and in the compression loading until failure test.

CONCLUSION

 The MUC-2TS treatment produced biomechanical properties equivalent to the AO-3TLS treatment for PIP joint arthrodesis.

Toe-to-Finger Vascularized Joint Transfers for Proximal Interphalangeal Joint Reconstruction: A Systematic Review

Vascularized joint transfer (VJT) from the proximal interphalangeal joint (PIPJ) of the toe is an attractive reconstructive option in cases of nonsalvageable finger PIPJ but is limited by equivocal functional outcomes. This systematic review aims to provide an update on vascularized toe-to-finger PIPJ transfers, examining functional outcomes, complications, and the latest refinements in operative technique. A systematic review of the available literature was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies examining vascularized toe-to-finger PIPJ transfer for post-traumatic indications were included for analysis. Outcomes assessed included postoperative active range of motion, extension lag, and complications. Thirteen studies examining 210 VJTs were analyzed. Five VJTs experienced microsurgical failure giving an overall survival rate of 97.6%. Average postoperative PIPJ active range of motion (ROM) was 40.3° ± 12.9°, with an average extensor lag of 29° ± 10.5° and mean flexion of 68.9° ± 10.9°. For studies reporting complication outcomes, 59/162 complications were seen. No significant differences were seen between studies published prior to 2013 and after 2013 when comparing digital ROM (P = .123), flexion (P = .602), and extensor lag (P = .280). Studies using a reconstructive algorithm based on prior assessment of the donor toe central slip and recipient finger anatomy had significantly improved ROM outcomes (P = .013). Although VJT provides a reliable option for autologous reconstruction in posttraumatic joints, it is limited by impaired postoperative ROM. Careful assessment of the donor toe and recipient finger anatomy followed by systematic and meticulous reconstruction may lead to improved functional outcomes.

Concomitant Dislocation of the Hallucal Interphalangeal Joint and Extra-Articular Dislocation of Its Sesamoid: A Case Report

CASE

A 22-year-old man sustained closed dislocation of the hallucal interphalangeal joint (HIPJ). Painful limitation of movements persisted 2 months after closed reduction. Magnetic resonance imaging revealed dislocation of the hallucal interphalangeal joint sesamoid (HIPJS) from its intra-articular attachment on the superior surface of the plantar plate to an extra-articular subcutaneous location, plantar and lateral to the flexor hallucis longus tendon. The HIPJS was enucleated through a plantar approach, and the foot remains pain-free 18 months later.

CONCLUSIONS

This case represents an unusual combination of HIPJ dislocation and extra-articular dislocation of its sesamoid. Raised awareness of the HIPJS, its normal anatomical location, and configuration will avoid delayed diagnosis.

Percutaneous Reduction of a Dislocation of the Interphalangeal Joint of the Great Toe: A Case Report

Dorsal dislocation of the interphalangeal joint of the great toe is quite rare. Closed reduction is often attempted in the emergency setting, but this measure is seldom successful because of invagination of the sesamoid-plantar plate complex into the interphalangeal space. Generally, open reduction is indicated when closed reduction fails. In this report, percutaneous reduction of the incarcerated sesamoid was performed under local and intraarticular anesthesia at our outpatient clinic, leading to successful reduction.

Use of a locking compression plate for equine proximal interphalangeal joint arthrodesis: 29 cases (2008-2014)

OBJECTIVE To describe clinical use of a locking compression plate (LCP) for proximal interphalangeal joint (PIPJ) arthrodesis in horses and compare outcomes for horses that underwent the procedure as treatment for fracture of the middle phalanx (P2) versus other causes. DESIGN Retrospective case series. ANIMALS 29 client-owned horses. PROCEDURES Medical records of 2 veterinary teaching hospitals from 2008 through 2014 were reviewed to identify horses that underwent PIPJ arthrodesis of 1 limb. Signalment, surgical, and outcome-related variables were recorded. Owners were contacted from 1 to 6 years after surgery to determine rehabilitation time, current use of the horse, and overall owner satisfaction with the procedure. Success was determined on the basis of owner satisfaction and outcome for intended use. Variables of interest were compared statistically between horses that underwent surgery for P2 fracture versus other reasons. RESULTS 14 horses underwent surgery for treatment of P2 fracture, and 15 had surgery because of osteoarthritis, subluxation, or osteochondrosis. Median convalescent time after surgery (with no riding or unrestricted exercise) was 7 months. Four horses were euthanized; of 23 known alive at follow-up, 22 were not lame, and 18 had returned to their intended use (8 and 10 at higher and lower owner-reported levels of work, respectively). Horses undergoing arthrodesis for reasons other than fracture were significantly more likely to return to their previous level of work. Twenty-two of 24 owners contacted indicated satisfaction with the procedure. CONCLUSIONS AND CLINICAL RELEVANCE Surgical arthrodesis of the PIPJ was successful in most horses of the study population. Various nuances of the system for fracture repair need to be understood prior to its use.

Comparative Study of Intramedullary Hammertoe Fixation

BACKGROUND

Temporary Kirschner wire fixation (K-wire) is a widely used, low-cost fixation method for the correction of hammertoe deformity. Reported complications associated with K-wires prompted the development of new implants over the past decade. However, there is a lack of literature on comparative studies analyzing functional outcomes using validated questionnaires. The purpose of this study was to analyze functional outcomes in patients who had undergone proximal interphalangeal joint fusion using 2 types of intramedullary implant, the Smart Toe and the TenFuse, and to compare them with the outcomes in patients treated with standard K-wire fixation.

METHODS

A retrospective review of operative hammertoe correction by a single surgeon was performed in 96 patients followed for more than 12 months. Functional outcome was assessed using the Foot Function Index (FFI), the Short Form 36 (SF-36), and the 10-point visual analog scale (VAS) validated questionnaires. Complications and fusion rates were also evaluated. Several patients in the study underwent corrections in different toes; thus, a total of 186 toes were included in the study. From these, 65 toes (34.9%) were treated with K-wire fixation, 94 (50.5%) with Smart Toe titanium implant, and 27 (14.5%) with TenFuse allograft implant.

RESULTS

No statistically significant differences in functional outcome and incidence of complications were observed among the 3 fixation groups, although the 2 intramedullary implants were associated with greater fusion rates and patient satisfaction. Breakage of the Smart Toe implant was significantly higher than that of the other fixations, with 10.6% of implants breaking within the first year postoperatively. SF-36 and VAS scores decreased 12 months after surgery for the 3 types of fixation, with no statistically significant differences observed.

CONCLUSION

The use of Smart Toe and TenFuse implants provided operative outcomes comparable to those obtained using a K-wire fixation and slightly better patient satisfaction. Our results suggest that utilization of these implants for hammertoe correction was a reasonable choice that provided good alignment, pain reduction, and improved function at final follow-up. However, they are more expensive than K-wires. For this reason, in-depth cost-benefit studies would be required to justify their use as a standard treatment.

LEVEL OF EVIDENCE

Level III, comparative series.

Treatment of Rigid Hammer-Toe Deformity: Permanent Versus Removable Implant Selection

Hammer-toe deformities that fail nonoperative treatment can be successfully addressed with proximal interphalangeal joint resection arthroplasty or fusion. The goal of surgery is to eliminate the deformity and rigidly fix the toe in a well-aligned position. Hammer-toe correction procedures can be performed with temporary Kirschner wire (K-wire) fixation for 3 to 6 weeks with high success rates. Pain relief with successful hammer-toe correction approaches 90%; patient satisfaction rates approximate 84%. Although complication rates are rare in most series, there remains a concern regarding exposed temporary K-wire fixation, which has led to the development of multiple permanent internal fixation options.

Minimally invasive proximal interphalangeal joint arthrodesis using a locking compression plate and tissue engineering in horses: a pilot study

This pilot study assessed the efficacy of 2 minimally invasive techniques for proximal interphalangeal (PIP) joint arthrodesis in horses. The PIP joints of both forelimbs (n = 6) were stabilized with locking compression plates (LCP) using a minimally invasive technique (LCP technique). Subsequently, for 1 randomly selected PIP joint of each horse, surgical drilling (SurD) was performed and tissue engineering (TE) was applied (LCP/SurD/TE technique). Minimally invasive PIP joint arthrodesis with LCP demonstrated low postoperative infection rates. Gross and histological evaluations revealed considerable destruction of the articular cartilage in the LCP/SurD/TE-treated joints. In contrast, almost no destruction of the cartilage was observed in the LCP-treated joints. Our results suggest that the LCP technique alone is not sufficient for PIP joint arthrodesis and that the LCP/SurD/TE technique may be useful for PIP joint arthrodesis in horses.

Irreducible longitudinal distraction-dislocation of the hallux interphalangeal joint

Although volar and dorsal dislocations have been described in the literature, dislocation of the hallux interphalangeal joint is a disorder rarely encountered by orthopedic and foot surgeons. In this article, we report a case of a distinct irreducible longitudinal distraction-dislocation that originally presented to the emergency department but required open reduction in the operating room. We also describe the presentation, anatomy, and treatment of this unique disorder.

Using a bone allograft to fixate proximal interphalangeal joint arthrodesis

Digital contractures are a very common deformity of the foot and ankle that require surgical correction. It has been shown that arthrodesis provides a better long-term result than arthroplasty of the interphalangeal joints. Arthroplasties usually require K-wire fixation that presents potential complications, such as pin tract infection. This study presents a new cadaveric bone matrix allograft to be used as rigid internal fixation for proximal interphalangeal joint arthrodesis. The purpose of using the allograft as a fixation device is to achieve solid bone fusion and avoid the potential complications of external pin fixation. Arthrodesis of the proximal interphalangeal joint was performed on 63 toes in 32 patients using TenFUSE (Solana Surgical, Memphis, TN), a sterile bone matrix allograft. The authors found 97% fusion rate with no complications reported to this date. It was concluded that this bone matrix allograft provides excellent results and is a suitable alternative fixation device for correction of hammer toe deformity.

LEVEL OF EVIDENCE

Level V.

Safety area for proximal metatarsal procedures

BACKGROUND

Forefoot and tarsometatarsal surgery may be performed on the first and second metatarsal through the intermetatarsal space. However, no study has identified the safety area of the proximal metatarsal bone to avoid vascular injury.

METHODS

One hundred and twenty-two uninjured embalmed feet of 31 female and 33 male cadavers aged 15 to 91 years (mean, 69.9 years) were studied. The dorsalis pedis artery was identified and dissected from its origin to the deep plantar artery. The distances from the artery to the dorsomedial aspect of first metatarsal bone, from the artery to the first tarsometatarsal joint, and from dorsalis pedis artery to the most plantar surface of second metatarsal bone were measured.

RESULTS

The distance from the artery to the first tarsometatarsal joint averaged 23.1 mm (range, 12-31 mm) and the distance from the artery to the most plantar surface of the second metatarsal bone averaged 6.3 mm (range, 3-13 mm).

CONCLUSIONS

The safety area for proximal metatarsal procedure is about a 69-mm(2) triangular area (23 mm from first tarsometatarsal joint and 6 mm from the most plantar surface of the second metatarsal bone).

CLINICAL RELEVANCE

The study provides information of normal location and variation of deep plantar artery is which related to medial midfoot complex. This information may be used during proximal metatarsal procedures.

Digital arthrodesis: current fixation techniques

Several hammertoe implant devices have recently been introduced in an attempt to provide optimal fixation for proximal interphalangeal joint arthrodesis. This article reviews these implants individually, and discusses their advantages and disadvantages. There is a lack of research with long-term follow-up available for these devices. Percutaneous Kirschner-wire fixation persists as a time-honored and effective method of fixation. The buried Kirschner-wire technique is also an effective, cost-conscious option, with many of the same advantages as newer implantable devices.

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.

Outpatient percutaneous flexor tenotomies for management of diabetic claw toe deformities with ulcers: a preliminary report

OBJECTIVE

To retrospectively review the outcomes of percutaneous flexor tenotomies of diabetic claw toes with ulcers or pending ulcers.

METHODS

We undertook a retrospective chart review between January 1999 and June 2005 to identify those patients who had undergone a percutaneous flexor tenotomy for diabetic claw toe deformities. We identified 34 toes in 14 patients. Of these, 24 toes had ulcerations at the terminal aspect and 3 had radiographic evidence of osteomyelitis of the terminal phalange. All patients had palpable pulses and good capillary refill. A percutaneous flexor tenotomy was performed on all toes in an outpatient clinic; patients with a rigid flexor contracture at the proximal interphalangeal joint underwent an osteoclaysis to correct a portion of the deformity.

RESULTS

The average follow-up was 13 months. All patients with ulcers healed and there were no significant complications. Those without osteomyelitis healed within an average of 3 weeks and those with osteomyelitis healed within an average of 8 weeks.

CONCLUSION

A percutaneous flexor tenotomy with osteoclasis of the proximal interphalangeal joint performed in an outpatient clinic is a safe and effective method to off-load the tip of the toe so that that ulcer healing can occur. The presence of osteomyelitis is not a contraindication for this technique; however, an increased healing time can be expected.

[Treatment of hallux valgus by remodeling the bone and articular morhpology of the first metatarsophalangeal joint]

OBJECTIVE

To evaluate the physiological function and the anatomic structure of the first metatarsophalangeal joint for the patient with hallux valgus after a remodeling operation with the Keller's method.

METHODS

From April 2004 to November 2006, the first metatarsophalangeal joints in 11 patients (22 feet) with hallux valgus were remodeled with the Keller's operation. There were 3 males and 8 females, aged 51-73 years. According to the Piggot typing standard, there were 17 feet of type I (deflexion) and 5 feet of type II (semiluxation). The hallux valgus angles (HVAs) were 24-49 degrees (average, 37 degrees). The intermetatarsal angles (IMAs) were 9.0-13.5 degrees (average, 11.5 degrees). The curative effect and the anatomic structure were evaluated by the follow-up and the X-ray examination.

RESULTS

All the cases were followed up for 6 to 30 months after operation (average, 14 months). According to the standard of ZHU Li Hua, et al, the results were excellent in 18 feet, good in 3 feet, and poor in 1 foot. The X-ray films showed that the first metatarsophalangeal joint of 14 feet developed mortar-like false articulation, and 8 feet developed partial false articulation. HVAs were 7-16 degrees (average, 11 degrees). IMAs were 9.0-13.5 degrees (average, 11.5 degrees). According to the Piggot typing standard, there were 12 feet of type I (fitter) and 10 feet of type II (deflexion).

CONCLUSION

For the patients with hallux valgus, the remodeling of the first metatarsophalangeal joint by the Keller's operation can rectify HVA, improve the stability of the joints, and prevent occurrence of the insufficient muscle strength after operation.

Septic Arthritis of the Distal Interphalangeal Joint in Cattle: Comparison of Digital Amputation and Joint Resection by Solar Approach

OBJECTIVE

To determine in cattle with septic arthritis of the distal interphalangeal joint (SADIJ) the efficacy of resection of the distal interphalangeal joint (JRES) as a digit salvage technique compared with digital amputation (DAMP).

STUDY DESIGN

Prospective, randomized clinical study.

ANIMALS

German Holstein-Friesian dairy cattle with SADIJ of 1 hind limb (n=52).

METHODS

SADIJ diagnosis was based on clinical examination and radiography. Cows were randomly assigned with owner consent to DAMP (n=26) or JRES (n=26). After JRES, a wooden block was fixed to the partner claw in combination with a tipping claw prophylaxis.

RESULTS

After surgery, degree of lameness improved significantly faster after DAMP than after JRES. New claw diseases in the opposite limb occurred more frequently after JRES (n=6) than after DAMP (n=1). New claw defects developed in the partner claw on the operated limb in 6 cows after DAMP compared with 1 after JRES. Tipping claw was observed in 50% of JRES cows at day 180. Mean life span between groups was not significantly different (DAMP=13.5 months, JRES=10.9 months).

CONCLUSION

Higher surgical and postsurgical expenditures for JRES were not counterbalanced by a longer productive life; however, frequent disease of the partner claw of cows after DAMP should be considered a critical point, as this generally leads to culling.

CLINICAL RELEVANCE

The higher expenditure for JRES can be justified only for young, valuable cattle.

Varus instability of the hallux interphalangeal joint in a taekwondo athlete

The hallux interphalangeal joint is stable in the transverse plane and there have been only a few reports of varus instability of this joint. A case is described of varus subluxation of the hallux interphalangeal joint in a taekwondo athlete and the surgical outcome after reconstruction of the collateral ligament. Taekwondo athletes, who require fast powerful kicks, should be warned about this type of forefoot injury.

Osteochondral fragments involving the dorsomedial aspect of the proximal interphalangeal joint in young horses: 6 cases (1997–2006)

OBJECTIVE

To determine clinical and diagnostic imaging findings in young horses with osteochondral fragments involving the dorsomedial aspect of the proximal interphalangeal (PIP) joint.

DESIGN

Retrospective case series.

ANIMALS

6 horses.

PROCEDURES

Medical records were reviewed. Follow-up information was obtained through telephone conversations with owners or trainers or by examining race records.

RESULTS

Horses were between 1 and 4 years old. Three had bilateral osteochondral fragments in the forelimbs (n = 2 horses) or hind limbs (1). Radiographically, all but 1 fragment seemed to originate from the dorsomedial aspect of the distal end of the first phalanx. Fragment size ranged from 6 x 9 mm to 11 x 21 mm. Three horses had lameness referable to the region of the affected joint; the other 3 horses did not have clinical signs referable to affected PIP joints. Two horses were euthanized shortly after diagnosis at the owners' request because of concerns that the horses would be unsuited for their intended athletic use. Two of the 3 horses in which fragments were incidental findings were able to race successfully, although 1 received intra-articular corticosteroid treatments; the third was retired because of unrelated orthopedic problems.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggested that osteochondral fragments involving the dorsomedial aspect of the PIP joint may be an incidental finding in young horses. Given the absence of clinical signs in 5 of 9 affected joints and the fact that 3 of 6 horses were affected bilaterally, a developmental origin of the fragments was suspected.

Excision arthroplasty of the interphalangeal joint as an alternative to digit amputation in two dogs

Excision arthroplasty of the interphalangeal joint was used as an alternative to digit amputation for comminuted fractures of the phalangeal bones in two dogs. Both patients had return of pain-free use of the affected limb, even though both weight-bearing digits were involved in one case. This type of surgery might prove to be superior to the more invasive digit amputation, salvaging the digits and providing a better functional outcome.

A modified Hohmann method for hallux valgus and telescoping osteotomy for lesser toe deformities in patients with rheumatoid arthritis

To preserve the function of metatarsophalangeal joints and to ensure forefoot stability in patients with rheumatoid arthritis (RA), we performed a modified Hohmann method for hallux valgus (HV) and telescoping osteotomy or shortening of lesser toe deformities. Forty-seven RA patients (90 feet) with severe HV and forefoot deformities were examined. The indication for the procedure in all the patients was disabling foot pain secondary to intractable plantar callosities below the lesser metatarsal heads and painful HV deformities. The HV and intermetatarsal (M1M2) angles and sesamoid complex were measured on the preoperative and postoperative roentgenograms. Visual analogue scales were studied preoperatively, postoperatively, and in the follow-up period. HV and M1M2 angles significantly improved compared between the pre- and postoperative conditions. Out of the 47 patients, 78.9% were satisfied with the results of the operation, 8.9% were unsatisfied, and 12.2% reported fair results. There were several complications, such as painful callosity, which was recurrent in seven feet, and delayed wound healing was observed in two out of the 90 feet. A modified Hohmann method and abductor hallucis muscle correction are effective in relieving pain and ensuring the bony union of the great toe in spite of severe osteoporosis.

Arthroplasty of the interphalangeal joint of the great toe using costal osteochondral grafting

Although many reports have been published on the usefulness of costal cartilage grafting in the reconstruction of interphalangeal joints of fingers, there are only a few published reports on the reconstruction of interphalangeal joints of toes. We describe a 21-year-old woman with a tissue defect of the dorsum pedis and a partial defect of the interphalangeal joint of the great toe caused by a motor-vehicle accident. We attempted arthroplasty using a free latissimus dorsi myocutaneous flap and a costal osteochondral graft. The grafted rib and cartilage survived, allowing the patient to resume functional ambulation for day-to-day activities. Arthroplasty using costal osteochondral grafts seems to be an effective means of reconstructing the interphalangeal joints of toes.

Proximal interphalangeal joint arthrodesis using a combination plate-screw technique in 53 horses (1994-2003)

REASONS FOR PERFORMING STUDY

A method for proximal interphalangeal joint (PIP joint) arthrodesis that provides a stable fixation and minimal duration of cast support is evaluated retrospectively.

OBJECTIVES

Evaluate the clinical use of a combined plate-screw method for PIP joint arthrodesis in a large number of horses.

METHODS

The records of 53 horses undergoing PIP joint arthrodesis were reviewed. Arthrodesis was performed with a dorsally placed 3-, 4- or 5-hole narrow dynamic compression plate (DCP) with 2 transarticular cortex screws placed in lag fashion either side of the plate. Subject details, clinical presentation, radiographic findings, surgical technique, post operative treatment and complications were recorded. Long-term follow up (mean 3 years) was obtained for 46 horses.

RESULTS

Arthrodesis procedures (n = 58) were performed on 53 horses with a DCP in combination with transarticular cortex screws placed in lag fashion. Conditions treated were osteoarthritis (OA) of the PIP joint, fracture of middle phalanx, PIP joint subluxation, subchondral cystic lesions and degenerative joint disease secondary to sepsis. Time of post operative cast application was 14 days. Overall 40/46 (87%) horses could be used as intended including 20/25 (81%) forelimb and 20/21 (95%) hindlimb arthrodeses. Twenty-three of 27 (85%) horses used for performance had successful outcomes. Complications included implant infection, cast sores and partial implant failure.

CONCLUSIONS

PIP joint arthrodesis using a DCP and transarticular cortex screws placed in lag fashion provides a stable construct and short casting period with minimal complications. The prognosis for return to performance was excellent for horses treated with hindlimb PIP joint arthrodesis and good for forelimb arthrodesis.

POTENTIAL RELEVANCE

Use of a combination technique for PIP joint arthrodesis allows a high proportion of horses with pastern joint disease to be returned to their athletic potential.

Ipsilateral arthrodesis of the metatarsophalangeal and interphalangeal joints of the hallux

BACKGROUND

Arthrodesis of the metatarsophalangeal joint of the hallux is frequently used for treatment of a variety of disorders. However, occasionally patients who have complex deformities or degenerative changes of the hallux require reconstruction of both the metatarsophalangeal and interphalangeal joints. There is concern that arthrodesis of both the metatarsophalangeal and ipsilateral interphalangeal joints could be problematic, interfering with the toe-off phase of gait or with shoewear.

METHODS

A retrospective evaluation of seven feet in five patients who had simultaneous arthrodesis of the metatarsophalangeal and ipsilateral interphalangeal joints of the hallux was undertaken. These cases represented all the patients who had this procedure within the practice of three orthopaedic foot and ankle specialists, totaling over 50 surgeon-years of experience. The indication for surgery in all patients was moderate to severe pain with ambulation with severe fixed deformity of both the interphalangeal and metatarsophalangeal joints of the hallux. All patients had pain that limited their ambulation and interfered with their daily activities. All patients required modified shoewear to accommodate their foot deformity. The mean age of patients was 53 years. The patients were evaluated by questionnaire and radiographic examination.

RESULTS

At an average of 46 months followup, all patients had resolution of their pain and were able to wear nonprescription shoes. All had limitations that interfered with full athletic activities but had no limitation of daily activities. Three patients who were employed returned to their occupations and two who were not employed were able to continue housework.

CONCLUSION

Arthrodesis of the metatarsophalangeal and ipsilateral interphalangeal joints of the hallux results in painless function in patients with moderate demands.

Course of damage to the hallux over 5 years after forefoot resection arthroplasty in rheumatoid arthritis patients

A retrospective study of 34 feet from 20 consecutive patients with rheumatoid arthritis was performed to investigate the development of damage to the hallux over 5 years after forefoot resection arthroplasty. Radiographically we analysed changes in two valgus angles and the interphalangeal joint (IP) damage of the hallux. These parameters were measured preoperatively, 12 months postoperatively, and at the latest follow-up. Although the average HVA (between the first metatarsal and the proximal phalanx) significantly decreased from 38.7 degrees preoperatively to 8.66 degrees postoperatively, the angle increased to 23.0 degrees during the first 12 months following surgery. Further deterioration of the angle at the last follow-up was not detected (25.3 degrees ; P=0.252). The average IPV (between the proximal phalanx and the distal phalanx) angle significantly increased from 6.65 degrees preoperatively to 12.1 degrees 12 months postoperatively and thereafter slightly increased to 13.3 degrees at the latest follow-up. The average of the Sharp/van der Heijde score of the IP joint significantly increased from 5.71 preoperatively to 8.58 12 months postoperatively and thereafter slightly increased to 9.65 at the latest follow-up. The deterioration and destruction process of the hallux after resection arthroplasty occurred soon after surgery, and the progression of the deformity was temporary.

Pediatric longitudinal epiphyseal bracket: Review and case presentation

The longitudinal epiphyseal bracket is a rare deformity affecting the long and short bones of the hands and feet, creating an aberration in growth. The deformity is present in 2% to 14% of congenital hand and foot deformities, with 11% of all cases found in the great toe. Ultrasound may then be used to confirm the diagnosis. Radiographs usually show the presence of a bracket epiphysis once there is some ossification, but until then, the radiographs can appear normal. With the use of ultrasound, a suspected preossified bracket can be visualized and can establish the diagnosis. The purpose of this article is to present such a case with a preossified epiphyseal bracket of the great toe. The child presented initially with unremarkable x-rays, but the diagnosis was made with clinical suspicion and use of ultrasound. After surgical resection of the brackets, there was progressive improvement in the short-term follow-up. Long-term follow-up is essential until skeletal maturity, and, if the deformity persists, further surgical care may need to be implemented.

A bioabsorbable fixation implant for use in proximal interphalangeal joint (hammer toe) arthrodesis: Biomechanical testing in a synthetic bone substrate

The surgical correction of hammer toe deformity of the lesser toes is one of the most commonly performed forefoot procedures. In general, percutaneous Kirschner wires are used to provide fixation to the resected proximal interphalangeal joint. Although these wires are effective, issues such as pin tract infections as well as difficult postoperative management by patients make alternative fixation methods desirable. This study biomechanically compared a threaded/barbed bioabsorbable fixation implant made of a copolymer of 82% poly-L-lactic acid and 18% polyglycolic acid with a 1.57-mm Kirschner wire using the devices to fix 2 synthetic bone blocks together. Constructs were evaluated by applying a cantilever load, which simulated a plantar force on the middle phalanx. In all cases, the failure mode was bending of the implant, with no devices fracturing. The stiffness (approximately 6-9 N/mm) and peak load (approximately 8-9 N) of the constructs using the 2 systems were equivalent. Accelerated aging at elevated temperature (47 degrees C) in a buffer solution showed that there was no reduction in mechanical properties of the bioabsorbable system after the equivalent of nearly 6 weeks in a simulated in vivo (37 degrees C) environment. These results suggest that the bioabsorbable implant would be a suitable fixation device for the hammer toe procedure.

Neglected irreducible dislocation of the interphalangeal joint of the great toe: a case report

Irreducible dorsal dislocation of the interphalangeal joint of the great toe is rare. We report a case of a 58-year-old man with an irreducible interphalangeal joint of the great toe that had been untreated for 4 years. The mechanism of this injury was thought to be a combination of axial loading with a hyperextension force when the patient hit his great toe against a pipe. Invagination of the sesamoid became a barrier for manual reduction attempted after the initial injury. The patient did not seek treatment because of the minor deformity of the affected great toe and lack of severe symptoms. One year later, symptoms eventually developed on the plantar aspect of the great toe, particularly when the patient was walking upstairs. He decided to seek treatment as pain worsened and he became more active when he changed occupations 4 years later. Manual reduction was impossible. The patient was treated with operative exploration of the joint and arthrodesis of the great toe. The operative course was uneventful. At 4 years after surgery, the patient could walk, run, and walk up and down stairs without discomfort.

Skin excision and osteophyte removal is not required in the surgical treatment of digital myxoid cysts

BACKGROUND

Digital myxoid cysts (DMCs) are ganglia of the adjacent distal interphalangeal joint (DIPJ) caused by leakage of fluid from the joint into the surrounding tissues. The connection between the DIPJ and the cyst can be identified by the injection of methylene blue into the DIPJ. However, the injection of methylene blue into the DIPJ is difficult and time-consuming. Based on this understanding of the cause of DMCs, we have used a surgical technique to treat DMCs without the need for skin excision. Herein, we have adapted the technique and demonstrated that precise leakage point identification is not required for treatment success, thus reducing the potential postoperative morbidity, reducing the operative time, and simplifying the surgical technique.

DESIGN

This was a prospective, open, nonrandomized trial of therapy. A skin flap was designed to include the cyst and tissues from the cyst to the DIPJ. No skin excision was required, and no osteophyte removal was attempted.

SETTING

University dermatology department.

PATIENTS

Thirty-two consecutive symptomatic subjects with 26 finger DMCs and 6 toe DMCs. No patient had been previously treated.

MAIN OUTCOME MEASURES

Clinical assessment postoperatively and recurrence rate after a minimum follow-up of 8 months.

RESULTS

Of the 26 finger DMCs, 24 (92.3%) remained healed at 8 months; and of the 6 toe DMCs, 2 (33.3%) remained healed at 8 months.

CONCLUSIONS

Digital myxoid cysts are caused by leakage of joint fluid from the DIPJ to the cyst. The leakage point is sealed in the healing process that occurs after a flap is raised and re-sited. The flap must be designed to include the undersurface of the cyst and the tissues between the DIPJ and the cyst. No skin excision or osteophyte removal is required. The procedure is not recommended for DMCs of the toes.

Rail external fixation for stabilization of closing base wedge osteotomies and lapidus procedures: a retrospective analysis of sixteen cases

This is a retrospective study of 16 cases of proximal first-ray procedures with rail external fixation. Arthrodesis of the first metatarsal-cuneiform joint was performed on 11 feet, and a closing base-wedge osteotomy was performed on 5 feet. Heel weightbearing in a surgical shoe with ankle joint mobilization was the standard postoperative protocol. Thirteen women and one man with an average age of 41 years (range, 16-64 years) were evaluated, with an average follow-up of 15.12 months (range, 10-24 months). The mean duration of frame application among all patients was 6.75 weeks (range, 2-10 weeks; 7 weeks for the base wedge procedures; 6.64 weeks for the lapidus). Multiple complications developed. Ten patients developed pin-tract infections: 5 required isolated pin removal, whereas 2 required removal of the entire frame because of the severity of infection. Seven patients developed pin loosening. Two patients developed cellulitis requiring long-term intravenous antibiotic therapy. Two nonunions occurred, both with the lapidus procedure, and one was symptomatic. Ten of the 16 patients reported they would have surgery again. Monolateral external rail fixation in combination with heel weightbearing and ankle mobilization demonstrated a high complication rate when used for proximal first-ray procedures. The technique as described is not recommended for routine use with the lapidus and base wedge osteotomy procedures.

Arthrodesis of the equine proximal interphalangeal joint: a mechanical comparison of 2 parallel 5.5 mm cortical screws and 3 parallel 5.5 mm cortical screws

OBJECTIVE

To compare the biomechanical characteristics and mode of failure of 2 techniques using parallel 5.5 mm screws for pastern joint arthrodesis in horses.

STUDY DESIGN

Randomized block design, for horse (1-5), method of fixation (two 5.5 mm screws versus three 5.5 mm screws), side (right, left), and end (front, hind). Constructs were tested to failure in 3-point bending.

SAMPLE POPULATION

Twenty limbs (5 cadavers).

METHODS

A combined aiming device was used to facilitate screw placement. Two parallel 5.5 mm screws were inserted in lag fashion in 1 limb of a pair, and three 5.5 mm screws were inserted in the contralateral limb. Constructs were then tested in 3-point bending in a dorsal-to-palmar (plantar) direction using a materials testing machine at a loading rate of 19 mm/s. Maximal bending moment at failure and stiffness were obtained from bending moment-angular deformation curves.

RESULTS

There was no significant difference between two and three 5.5 mm screw constructs for bending moment and stiffness (P<.05). All constructs ultimately failed by bone fracture or screw bending. For proximal interphalangeal (PIP) joint arthrodesis constructs loaded in 3-point bending, no significant effect of treatment, side, or end on maximal bending moment or stiffness was detected.

CONCLUSIONS

Two 5.5 mm cortical screws inserted in parallel should provide a surgically simpler and equally strong PIP joint arthrodesis compared with three 5.5 mm cortical screws.

CLINICAL RELEVANCE

Two 5.5 mm cortical screws inserted in parallel for PIP joint arthrodesis should perform similarly under conditions used in this study, as three 5.5 mm screws inserted in a similar manner, when loaded under bending.

Gross anatomy of the interphalangeal joint of the great toe: implications for excision of plantar capsular accessory ossicles

Bony or cartilaginous ossicles occur at the plantar aspect of the interphalangeal joint of the great toe. The variation in pattern, prevalence, and anatomic relationships of these structures is not clearly established in the literature, especially in a Caucasian population. Without this knowledge, pathology at this joint may be underestimated and surgical approaches may be poorly planned particularly as radiographs underestimate the incidence of ossicles at this joint. The aims of this study were to determine the incidence and pattern of ossicles at this joint and to establish their anatomic relationships to aid planning the approach for their excision. The interphalangeal joint of the left hallux was dissected in 40 British Caucasian cadavers and the pattern of nodules and their anatomic relationships were established. In 27.5% of subjects, there was no identifiable ossicle and, in these specimens, the tendon of flexor hallucis longus was adherent to the joint capsule. In the remaining specimens (72.5%), a bursa separated the tendon of flexor hallucis longus from the plantar joint capsule and nodules were found embedded within the joint capsule. More than half (52.5%) of the specimens had a single nodule located centrally within the plantar capsule and the remaining 20% had two nodules lying within the capsule. This study shows that a large proportion of the population have either one or two bony or cartilaginous ossicles at this joint. It has also shown that, when present, these structures do not lie within the tendon of flexor hallucis longus and may be most safely excised from a medial approach.

Die Korrekturarthrodese des ersten Tarsometatarsalgelenks zur Behandlung des fortgeschrittenen Spreizfußes mit Halluxvalgus-Fehlstellung

OBJECTIVE

Arthrodesis of the first tarsometatarsal joint for the treatment of a painful splayfoot with the aim to restore a normal weight bearing on the first ray. Correction of hallux valgus deformity.

INDICATIONS

Advanced splayfoot deformity with a first intermetatarsal angle > 18 degrees. Hypermobility of the first tarsometatarsal joint with reduced weight bearing on the first ray and development of a transfer metatarsalgia. Painful, primary or secondary osteoarthritis of the first tarsometatarsal joint. Recurrence of splayfoot deformity after previous attempt at surgical correction. Elevation of the first ray such as after developmental clubfoot. Metatarsus primus varus deformity accompanied by hallux valgus in the presence of a hypermobile flatfoot.

CONTRAINDICATIONS

Minimal or moderate splayfoot deformity with a first intermetatarsal angle < 17 degrees and a clinically stable first tarsometatarsal joint. Untreated hindfoot deformities such as flatfoot combined with heel valgus. Inability to use walking aids for postoperative partial weight bearing. Insufficient circulation of forefoot.

SURGICAL TECHNIQUE

Dorsomedial incision overlying the first tarsometatarsal joint. Splitting of the extensor aponeurosis medial to the tendon of the extensor hallucis longus. Subperiosteal exposure of the first tarsometatarsal joint. Opening of the joint. Judicious removal of articular cartilage and resection of a laterally based bony wedge from the medial cuneiform for correction of the increased first intermetatarsal angle. Manual correction of the splayfoot with concomitant plantar displacement of the base of the first metatarsal. Selection of properly fitting fixed-angle plate and internal fixation. Soft-tissue correction at the first metatarsophalangeal joint or metatarsal neck osteotomy to realign the articular surface of the first metatarsal head.

RESULTS

Clinical and radiologic results based on 56 patients (64 feet) followed up for an average of 8.2 months.

COMPLICATIONS

one reflex sympathetic dystrophy, four nonunions of the first tarsometatarsal joint (6.2%). Radiologic evidence of consolidation at a mean of 9 weeks. Improvement of the first intermetatarsal angle from 20.4 degrees to 11.2 degrees. Pressure measurement showed a significantly improved load-carrying capacity of the first ray. The score of the American Orthopaedic Foot and Ankle Society improved significantly (p < 0.01) from 51 to 92 points.

Review of proximal interphalangeal joint excisional arthroplasty for the correction of second hammer toe deformity in 100 cases

BACKGROUND

The main bony procedures used in the treatment of second hammertoe are excisional arthroplasty and arthrodesis of the proximal interphalangeal (PIP) joint. While a number of studies have reported the outcomes after PIP joint arthrodesis, there are few reports of the outcome of excisional arthroplasty of the PIP joint for the correction of second hammertoes. The purpose of this study was to evaluate the long-term outcome of PIP joint excisional arthroplasty.

METHODS

Seventy-five patients (100 toes) who had excisional arthroplasty of the PIP joint for the correction of second hammertoe were reviewed at an average followup of 44 months. All patients were seen in clinic and were physically examined to assess the alignment and function of each digit. The radiographs were evaluated preoperatively. The AOFAS clinical rating scale was used preoperatively and at final followup. Patients were asked to rate their satisfaction on a scale of 0 to 10 and were asked if they would be happy to have the surgery under similar circumstances again.

RESULTS

The mean preoperative AOFAS clinical rating scale was 46. At final followup this increased to 94, showing an average improvement of 48 points (p < 0.0001). The mean satisfaction on a scale of 0 to 10 (with 0 equaling complete dissatisfaction and 10 complete satisfaction) was 9.3 (SD 1.3). One patient would not have been happy to undergo outpatient surgery again, because of a change in her social circumstances.

CONCLUSION

In a group of 75 patients who had PIP joint arthroplasty for the correction of second hammertoe, high levels of satisfaction were achieved. No serious complications were encountered, and revision surgery was required in just two cases. Floating toe was the most common complication encountered, and although this did decrease the level of patient satisfaction in seven patients it was not a cause of footwear irritation or pain in any patient.

Disorders of the hallucal interphalangeal joint

Most clinical presentations of the hallux concern the metatarsophalangeal joint; however, interphalangeal joint (IPJ) pathology also may be clinically significant. This article reviews conditions that commonly affect the hallucal IPJ and the appropriate treatment.

Digital mucoid cyst excision by using the bilobed flap technique and arthroplastic resection

There are a number of proposed causes and treatment approaches for digital mucoid cysts. The described treatment outcomes for this cyst have been variable, with the highest success rate reported with complete excision and single-lobe skin flap closure. This report describes a bilobed flap reconstruction in conjunction with resection of the head of the middle phalanx. A retrospective review was undertaken to evaluate the recurrence rate, complications, and patient satisfaction with this combined procedure. Fifteen patients with an average follow-up of 4.6 years were evaluated. There were no recurrences, flap failures, or other major complications. The use of this flap allows for greater exposure than traditional semi-elliptical incisions while allowing the wide excisional defects to be closed primarily.

Floating-toe deformity as a complication of the Weil osteotomy

BACKGROUND

The Weil osteotomy for treatment of central metatarsalgia is an oblique osteotomy of the metatarsal neck and shaft parallel to the ground that provides controlled shortening of the metatarsal without additional depression. It offers many advantages over more traditional osteotomies, including stability and a large area of bone-to-bone contact. However, a floating-toe deformity appears to be a common complication after this osteotomy.

METHODS

Between February, 2000 and February, 2003, 70 Weil osteotomies (in 26 patients) were done at one institution. Follow-up averaged 18.3 (6 to 36) months. Weightbearing radiographs were examined for shortening, subluxation, and for evidence of nonunion or malunion of the metatarsal head. Floating-toe deformity and mild recurrent tenderness were noted in the history and physical examination. The American Orthopaedic Foot and Ankle Society (AOFAS) Lesser Metatarsophalangeal-Interphalangeal Scale (LMIS) was used for outcome rating. At final follow-up, nonunion and malunion also were evaluated.

RESULTS

The median score of the AOFAS scale was 81 (19 to 95) points. Fifty-four percent of the osteotomies were done with a proximal interphalangeal (PIP) joint arthrodesis of the same ray, and we observed a higher occurrence of floating-toe deformity in this group of patients.

CONCLUSION

Although it may be associated with some complications, the Weil osteotomy is an effective and safe procedure for the treatment of central metatarsalgia. We conclude that floating-toe deformity is a common complication associated with PIP joint arthrodesis. Although it appears not to cause a functional impairment, concurrent PIP arthrodesis should be avoided to reduce the occurrence of floating toes.

Arthrodesis of the toe joints with an intramedullary cannulated screw for correction of hammertoe deformity

Twenty-four patients (37 feet, 51 toes) affected by hammertoe deformity of the lesser toes and treated surgically by arthrodesis of the proximal interphalangeal joint, stabilized with an intramedullary titanium cannulated screw, were reviewed 1-4 years after the operation. At follow-up, the arthrodesis was fused in 48 toes; three toes showed an asymptomatic radiographic nonunion, and in one of them the screw was broken. In seven toes, the cannulated screw was removed because of persistent pain at the tip of the toe where the head of the screw was located. In one case only, there was a late infection, with toe malalignment. All the patients were able to use street shoes 2 weeks after surgery. The average AOFAS score at follow-up was 86.54 points. Compared to the conventional temporary stabilization with an intramedullary Kirschner wire, the stabilization with a cannulated screw decreases the risk of infection, of radiographic nonunion, and of mallet toe deformity.

Metatarsal neck osteotomy with proximal interphalangeal joint resection fixed with a single temporary pin

BACKGROUND

Screws have been recommended for fixation of the site of the metatarsal osteotomy.

METHODS

A report is presented on one surgeon's experience with a temporary, single Kirschner wire instead of screws for fixation of metatarsal neck osteotomies combined with proximal interphalangeal (PIP) joint resection arthroplasty in patients with dislocated metatarsophalangeal (MTP) joints and severe hammertoe deformities. Eleven consecutive patients (13 toes) were treated between January 1999 and January 2002 (mean age, 69 years; range, 44-81 years; seven women, four men) at a tertiary care foot and ankle center. Records and radiographs were reviewed retrospectively, and all patients were examined at follow-up by one of the authors (mean follow-up, 13 months; range, 6-32 months).

RESULTS

All 13 metatarsal neck osteotomies had clinical and radiographic union by 6 weeks, with no evidence of nonunion, malunion, avascular necrosis of the metatarsal head, deep wound infection, pin-tract infection, broken pins, or other serious complications. Two metatarsals (18%) had minor residual plantar calluses beneath the metatarsal head. The mean postoperative American Orthopaedic Foot and Ankle Society score was 76 of 95 points possible. All patients were satisfied with the procedure and would do it again.

CONCLUSION

The use of a single, temporary K-wire provides adequate fixation for combined PIP joint resection arthroplasty and metatarsal neck osteotomy in patients with central metatarsalgia and severe hammertoe deformity.

Hallux IPJ fusion

Surgical arthrodesis of the hallux interphalangeal joint can be used as an isolated procedure to address painful or deformed joints or in conjunction with other procedures to create a better functioning first ray. This type of arthrodesis may be necessary in neuropathic patients to prevent ulcerations or amputations. Several etiologies exist that result in a deformity about the hallux IPJ, some can be pain-free, others may be extremely debilitating to a patient. Many different surgical approaches have been described and used when performing a hallux IPJ arthrodesis. Developing your own technique enables you to understand what works for you and your patients and allows you to determine the most effective way to achieve arthrodesis. The goal is to prevent painful nonunions and address the underlying deformity. It is also important to understand that a successful arthrodesis in a patient who has a neurological disorder is the only way to prevent recurring deformities secondary to the underlying disease process. The ability to properly work-up and surgically address deformities of the hallux interphalangeal joint is necessary for those who perform lower extremity surgery.

Techniques of digital arthrodesis: revisiting the old and discovering the new

Digital surgery is commonplace for foot and ankle surgeons. The techniques of arthrodesis are more exacting and complex than techniques of arthroplasty. They are generally performed in cases of more severe deformity or underlying biomechanical abnormalities, which strongly influence the development and propagation of the deformity. When performed properly in a patient with good compliance, the results are consistently good and rewarding to patients and surgeons. Attention to detail cannot be overemphasized in managing digital deformities. Failure to do so is likely to result in a less than satisfactory outcome for physician and patient. Traditional techniques are proven effective approaches. Meticulous attention to detail and precise execution of the procedure will minimize complications. The exact role of newer implants for fusion is yet to be determined. Further short-term and long-term experience will determine their role in foot surgery.

Proximal interphalangeal joint instability in the dog

A prospective study into the use of transarticular external skeletal fixation in the treatment of proximal interphalangeal instability was undertaken. Only dogs with soft tissue injuries were included. All the dogs except one were greyhounds or related breeds. A hypothesis was proposed that if the articular surfaces were held in normal congruency for a period of time then the development of periarticular fibrosis would alone give sufficient joint support. Joint congruency was maintained by the application of a unilateral external skeletal fixator for approximately three weeks. Complications were common and were due to frame impingement on the neighbouring digit, pin tract infection and pin loosening, and all resolved following frame removal and antibiotic therapy. Careful pin placement and prophylactic antibiotic treatment prevented complications in subsequent cases. All dogs returned to normal function with no lameness, with the exception of one racing greyhound which had a recurrence of the instability.

Treatment of mucous cysts of the toes

The outcome of surgically treated mucous cysts of the foot is poorly documented in the orthopaedic literature. This study reports on the treatment of mucous cysts of the toes by simple excision and joint debridement. This is in contrast to treatment of similar lesions in the fingers which is often treated by excision of the cyst, joint debridement, and rotational flap. Following this procedure on 15 patients (15 cysts), at a minimum of 2 years postoperatively, only one cyst had recurred at 9 months. All patients were satisfied by the cosmetic appearance of their toe. The authors reviewed the available literature on this condition and suggest that this method of treatment provides good functional and cosmetic results with a minimal rate of recurrence.

Autogenous bone graft interpositional arthrodesis for the correction of flail toe. A retrospective analysis of 22 procedures

Digital surgery is one of the most common types of surgery performed by foot and ankle surgeons. Flail toe is a complication that may occur after overaggressive resection arthroplasty of the proximal interphalangeal joint of the lesser toes. Correction of flail toe deformity has received little attention and has predominantly involved soft-tissue procedures. The authors' preferred technique for the surgical correction of flail toe is to place a unicortical autogenous bone graft (harvested from the ipsilateral calcaneus) within the revised proximal interphalangeal joint of the lesser toes to create a distraction arthrodesis. This technique allows restoration of digital length, stability, and purchase. A retrospective review of 22 such procedures in 13 patients is presented, along with a literature review of other procedures and a description of the authors' current surgical technique and postoperative management protocol. Overall success using the authors' procedure was 82%. Complications occurred in three patients, with one of the grafts showing complete resorption and two requiring additional surgical intervention owing to nonunion and malunion of toes.

[Use of grommet for Swanson flexible hinge toe implant arthroplasty for hallux valgus deformity of rheumatoid arthritis]

OBJECTIVES

We reviewed the results of arthroplasty of the great toe with hallux valgus in rheumatoid patients, using a Swanson flexible hinge toe implant protected by grommet.

MATERIALS AND METHODS

Sixteen patients (26 feet) with rheumatoid arthritis were operated on from 1996 to 1999. (fifteen women, one man). The average age was 59.8 years (range, 48-73 years). The average follow-up period was 3.0 years (range, 1.0-4.5 years). In each patient, the hallux valgus angle (HVA) was measured before and after surgery, and implant breakage and radiolucency around the implant were evaluated on radiographs.

RESULTS

Average HVA was 47.7 degrees preoperatively and 19.3 degrees postoperatively. No implant breakage was observed in 76.9% of the feet. Radiolucency of more than 2 mm was observed in only 3.8% of the feet.

CONCLUSIONS

These findings suggest that arthroplasty using a Swanson flexible hinge toe implant with a grommet is useful for treatment of hallux valgus in rheumatoid patients.

Hammer toe correction by arthrodesis of the proximal interphalangeal joint using a cortical bone allograft pin

In hammer toe correction by means of digital fusion, fixation so that the bone can unite while maintaining appropriate realignment can be a challenge. Metal fixation pins can be associated with many problems and potential complications. The author presents a method of rigid internal fixation using 2.4-mm-diameter pins fashioned out of freeze-dried allogeneic cortical bone. These devices avoid most of the risks of metal pins. Proximal interphalangeal joint arthrodesis using cortical bone pins was performed on 26 toes in 18 patients with very few complications. The author concludes that use of cortical bone pins can yield successful results in most cases. The outcomes of the fusions can be further enhanced by using flexor digitorum longus tendon transfer.