chapter 6b digital surgery

6.2 Digital SurgeryKeith Springer, DPM

The function of digits are:

• Stabilization

• Balance

• Kinesthetics

• Deceleration

Anatomy of the DigitsBone

Metatarsal head-is covered with articular cartilage distally and articulates with the base of the proximal pha-

lanx. The articular surface extends more proximal on the plantar surface then the dorsal surface. Plantarly there are

two condyles, which are separated by a notch where the flexor digitorum longus tendon lies. Proximal to the edge of

the articular cartilage is a groove, which is where the capsule attaches. Posterior to the groove are two tubercles, dor-

somedial and dorsolateral. These grooves are the attachments of the medial and lateral collateral ligaments and the

medial and lateral metatarsoglenoid suspensory ligaments.

Proximal phalanx-At the base and just distal to the articular cartilage is a groove for the insertion of the cap-

sule. On the plantar medial and plantar lateral aspects at each base there are tubercles for the attachments of the col-

lateral ligaments. The medial tubercle on the second toe receives the insertion of the first dorsal interossei and the

medial tubercle of three, four, five, the insertion of the plantar interossei. The lateral tubercle of two, three, four

receives the insertion of the two, three, four dorsal interossei and the fifth the insertion of the abductor digiti mini-

mi and the flexor digiti minimi. Just distal to the cartilage plantarly is the attachment of the plantar metatarsopha-

langeal ligament.

The shaft is convex dorsally and flat inferiorly. The head has articular cartilage, which extends more proximally

plantarly and has a groove for the passage of the flexor tendons. Plantarmedial and plantarlateral are tuberosities for

the origin of the collateral ligaments and just proximal to the articular surface marks the attachment of a very thin

capsule.

Middle phalanx-base has articular cartilage. There is a dorsomedial and dorso lateral tubercle for the insertion

of the collateral ligament and just distal to the articular surface marks the attachment of the capsule. The plantar lig-

ament attaches just distal to the articular cartilage. The middle slip of the extensor tendon inserts dorsally at its base.

The flexor digitorum brevis inserts on the medial and lateral sides at the base. At the head just proximal to the artic-

ular cartilage is the origin of the very thin capsule and there are plantar medial and plantar lateral tubercles for the

origin of the collateral ligaments.

Distal phalanx-triangular in shape. An articular surface is present only at the base with the insertion of the cap-

sule just distal to this surface and two small tubercles for the insertion of the collateral ligaments. At the base dorsal-

ly 2 slips of the extensor tendon inserts and plantarly at the base two slips of the FDL inserts.

ArthrologyMetatarsophalangeal joint-A discrete synovial joint. The capsule attaches more proximal plantarly then dorsal-

ly. The capsule is much thinner dorsally and is reinforced by the EDL and the extensor expansion. It is thicker medi-

ally and laterally and reinforced by the collateral ligaments. It is attached loosely both dorsally and plantarly to allow

for motion.

Surgery | Digital Surgery 517

The collateral ligaments are triangular in shape and blend with the capsule. They restrict transverse plane

motion. They run from the dorsomedial/dorsolateral tubercle on the metatarsal to the plantarmedial/plantarlateral

tubercle on the proximal phalanx.

The suspensory metatarsophalangeal ligament runs from the tubercles on the metatarsal heads into the plan-

tar pad. Along with the collateral ligament they appear as two distinct bands 68% of the time or as one triangular

band 32% of the time.

The plantar MPJ ligament (Glenoid ligament) reinforces and blends with the capsule. It strengthens the joint

plantarly. It is partially fibrocartilagenous and flexor plate, volar plate, plantar capsule forms the plantar pad or

plate. This pad is tightly attached to the proximal phalanx and loosely attached to the metatarsal allowing the proxi-

mal phalanx to move. Medially and laterally the pad is attached to the deep transverse metatarsal ligament. There is

a groove in the pad plantarly for the passage of the flexor tendons.

The motion is primarily sagittal with 50-60° of dorsiflexion and 30-40° plantarflexion. The plantar pad moves

with MPJ motion.

PIPJ & DIPJ- both are synovial joints(ginglymus or hinge). The motion is in the sagittal plane with more plan-

tarflexion then dorsiflexion. There is more motion at the PIPJ then the DIPJ. Both have a capsule and collateral liga-

ments that are tighter then at the MPJ. Both joints have a strong fibrous ligament plantarly similar to the MPJ.

Sometimes sesamoids are found at these IPJ’s (mostly seen at the PIPJ of two and three).

MuscleExtensor Digitorum Longus-four slips that insert into the middle and distal phalanges. Function is to extend

the four lesser toes, extend the ankle, a weak evertor and oppose the FDL.

Flexor Digitorum Longus-divides into four slips at the navicula where it receives the quadratus plantae inser-

tions and then gives rise to the lumbricle origins medially. They run in a sheath with the FDB at the metatarsal

heads created by the plantar aponeurosis. They insert plantarly into the base of the distal phalanx. They plantarflex

the MPJ, PIPJ, DIPJ and ankle and they are the antagonist of the EDL.

Extensor Digitorum Brevis-origin is the dorsolateral aspect of the calcaneus just anterior to the sinus tarsi.

Runs distally and divides into 4 with the first tendon being the EHB. There is NO EDB tendon to the fifth toe. Slips

two, three, four insert into the lateral aspect of the EDL just distal to the MPJ. The EDL & EDB form a trifurcate sys-

tem with the central portion inserting into the middle phalanx and the two outer slips into the distal phalanx. The

lateral slip of this trifurcate is often considered the EDB. (Fig. 1)

Figure 1.

518 The 2005 Podiatry Study Guide

Flexor Digitorum Brevis-origin is the medial calcaneal process. Divides into four slips and runs superficial

or plantar to the FDL. At the base of the proximal phalanx the tendon splits and allows the FDL to pass through. At

this level it is now dorsal to the FDL. The split unites and then inserts into the base of the middle phalanx on both

sides. Its function is to PF both the MPJ’s & PIPJ’s of toes two, three, four, five. (Fig. 2)

Figure 2.

Quadratus plantae-flexor digitorum accessorius-origin is the medial and lateral plantar calcaneus and inserts

into the FDL tendon laterally. It aids in the posterior pull of the FDL (see below).

Lumbricles-origin is the medial aspect of the FDL runs distal and medial and passes deep or plantar to the deep

transverse metatarsal ligament and inserts into the medial aspect of the extensor expansion. Its function is to plan-

tarflex the MPJ and dorsiflex the IPJ.

Plantar interossei-there are three. The origin is the medial aspect of the three, four, five metatarsal move distal-

ly and is dorsal to the deep transverse metatarsal ligament and insert into the medial tubercle of the proximal pha-

lanx the capsule and extensor expansion of the three, four, five toes. They adduct these three toes.

Dorsal interossei-There are four that arise form the adjacent sides of the metatarsals run distal and dorsal to

the deep transverse metatarsal ligament and insert into the tubercle of the base of the proximal phalanges and the

extensor expansion of toes two, three, four. The first dorsal interossei inserts into the medial two toe the two, three,

four dorsal interossei into the lateral aspect of toes two, three, four.

Abductor digiti minimi-lateral process of the calcaneus to the lateral plantar aspect of the proximal phalanx of

the 5th. It abducts and aids in plantarflexion

Flexor digiti minimi brevis-medial plantar base of the fifth metatarsal to the plantar lateral aspect of the base

of the proximal phalanx. Plantarflexes and abducts the fifth toe.


Extensor Expansion

Figure 3. Extensor Expansion

A fibroaponeuritic structure that anchors the EDL and EDB. It extends from the MPJ to the PIPJ. This

fibroaponeuritic structure extends around the medial and lateral aspect of the proximal phalanx and attaches plan-

tarly into the plantar plate, MPJ capsule, flexor tendon sheath and suspensory ligament. It does not attach directly to

bone. The fifth is the least developed. The two, three, four, and five differ from the hallux.

Proximally the fibers are oriented transversely and is called the extensor sling and distally the fibers are oriented

obliquely (from posterior inferior to anterior superior) and are called the extensor wing or extensor hood.

The lumbricles form the oblique border of the extensor wing medially and inserts into the central and medial

slip of the extensors. The lumbricles PF the MPJ and DF the IPJ. This occurs because the lumbricle when it fires

tightens the wing distally causing dorsiflexion of the PIPJ and slackens the sling proximally to yield to plantarflexion

of the MPJ by the flexors. This action is maintained by the lumbricles because they are plantar to the deep transverse

metatarsal ligament.

The dorsal and plantar interossei are dorsal to the deep transverse metatarsal ligament and are parallel to the

metatarsal bone axis. They insert primarily into the base of the proximal phalanx and minimally into the extensor

expansion. If they are in proper alignment they stabilize the MPJ. They do not plantarflex it.

The function of the extensor expansion is to keep the digit in a rectus position. When the extensors fire they

tend to dorsiflex the MPJ creating a tightening on the extensor sling and a slackening of the extensor wing. This

would create dorsiflexion of the MPJ and plantarflexion of the IPJ creating a hammertoe. The lumbricles when in

proper position fire and they tighten the extensor wing and slacken the extensor sling thus placing both joints into a

rectus position.

Plantar PlateOccurs at the MPJ’s & PIPJ’s and provides for a cushion for weight bearing forces. They are the most important

stabilizers of the MPJ. They have a strong attachment into the base of the proximal phalanx and a loose one into the

metatarsal head.


Plantar plate dysfunction-occurs due to toe off stress, chronic hyperextension, rupture with subluxation, and

dislocation. All this leads to hammertoes.

Etiology of Digital Deformities• Congenital

• Heredity

• Shoes-heel height

• Trauma

• Relative length of toes

• Hallux Valgus

• Arthritities and connective tissue diseases

• Neuromuscular diseases

• Biomechanical

Biomechanical etiologyFlexor Stabilization-most common being seen about 90% of the time. It is the result of the flexors gaining a

mechanical advantage over the intrinsics mostly the interossei. If we do a gait analysis, you see an increase in the

deformity primarily in mid-stance.

Extensor substitution-seen about 10% of the time. It occurs as a result of the anterior muscles gaining a

mechanical advantage over the intrinsics specifically the lumbricles. If we do a gait analysis, you see an increase in

the deformity primarily during swing phase.

Flexor substitution-least common etiology. Usually due to a weak triceps surae muscle. All of the posterior

muscles including the FDL must now overwork to plantarflex the ankle. The FDL aids in plantarflexing the ankle

and thus causes the toes to grasp the ground and eventually lead to hammer toes. We see an increase in the digital

deformity during the propulsive phase of gait.

It is important when evaluating digital deformities to do a gait analysis. This will provide the doctor with the

biomechanical etiology. This in turn will aid in selecting the proper surgical treatment.

Classification of Digital DeformitiesMallet toe-a one-joint deformity that involves plantarflexion of the distal interphalangeal joint.

Hammertoe-a two-joint deformity that involves dorsiflexion of the metatarsophalangeal joint and plantarflex-

ion of the proximal interphalangeal joint. The distal interphalangeal joint is in neutral.

Claw toe-a three joint deformity that involves dorsiflexion of the metatarsophalangeal joint and plantaflexion of

both the proximal and distal interphalangeal joints.

5th toes - rare to see a true hammering or claw toe. Usually one sees an adductovarus deformity with a keratotic

lesion overlying the PIPJ. The etiology is due to an imbalance in the posterior vector pull between the flexor digito-

rum longus and quadratus plantae muscle (Fig. 4). Seen mostly commonly due to excessive pronation and seen in

flexor stabilization.


Figure 4.

Hammered hallux-dorsiflexion of the 1st metatarsophalangeal joint and plantarflexion of the interphalangeal

joint. The etiology can be swing or stance phase but it is most commonly due to an iatrogenic cause.

Hallux malleus-plantarflexion on the interphalangeal joint. Mostly due to an iatrogenic cause.

Flexibility of Digital DeformitiesIt is important to know whether you have digital deformities that are completely flexible, semi-flexible (semi-

rigid) or rigid. Please note that the terms semi-flexible and semi-rigid can be used interchangeably. The flexibility of

the deformity influences the surgical procedure to be performed. If the deformity is totally flexible one thinks

towards doing soft tissue procedures. With any form of rigidity one thinks of performing osseous procedures.


Kellikian Push Up Test (Fig 5.)

Figure 5.

The examiner loads the fore foot and observes what happens to the metatarsophalangeal joints. It is important

to note that this is a test to see the flexibility of the MPJ’s only.• The flexibility of the interphalangeal joints is tested manually only

• Flexible-a joint that completely and totally reduces

• Semi-flexible or semi-rigid-a joint that can only be partially reducible

• Rigid-a joint that does not reduce at all

Surgical Management of Digital DeformitiesBefore selecting a surgical procedure one must first determine:

• Which deformity do we have

– Mallet toe

– Hammer toe

– Claw toe

• Etiology

– Flexor stabilization

– Extensor substitution

– Flexor substitution

• Flexibility

– Flexible

– Semi-flexible/semi-rigid

– Rigid


Osseous Management of Digital Deformities• Arthroplasty-creation of a new joint (PIPJ &/or DIPJ)

• Arthrodesis-fusion of PIPJ &/or DIPJ

Post arthroplasty-resection of the head of the proximal phalanx for a hammertoe that is semi-flexible (semi-

rigid), rigid with a flexor stabilization etiology. An arthroplasty of both the PIPJ & DIPJ can be done for a semi-flex-

ible (semi-rigid) claw toe with a flexor stabilization etiology. An arthroplasty of the DIPJ only is done for semi-flexi-

ble (semi-rigid) and rigid mallet toes.

Of the numerous surgeries that are described, the most universally performed procedure for a hammer toe has

been the Post arthroplasty. While it does little to restore the intrinsic muscle stabilization it does reduce the deformi-

ty and symptomotogy and it has withstood the test of time.

Arthroplasty for Hammer toesSkin Approaches Can Be:

• Dorsal linear

• Two longitudinal semi-elliptical

• Two transverse semi-elliptical incisions

• Medial or lateral linear incision

Tendon Approaches:• Transverse at the level of the PIPJ

• Linear through the tendon and retract medially and laterally

• Cut the extensor expansion and reflect the tendon either medially or laterally

Collateral Ligament• Both medial and lateral collateral ligaments should be severed

Bone• The head should be removed just as the bone begins to flare

• One can use:

– Double action bone cutter

– Rongeur

– Saw (oscillating, reciprocating etc)

– Giglie saw

– Osteotome and mallet

Closure• Tendon re-approximated with absorbable suture

• Skin closed with absorbable or non-absorbable suture

Arthroplasty for a Mallet ToeArthroplasty for a mallet toe is exactly the same as that for a hammer toe except the bone is removed from the

head of the middle phalanx.

Arthroplasty for a claw toe-a combination of the procedure for a hammer plus a mallet toe. The incisions can

be straight linear, a T-shaped incision or two transverse incisions at the level of the joints


Arthroplasty for fifth toesThe arthroplasty procedure for fifth toes is exactly the same as is done for hammer toes two, three, and four.

Plus, a lateral middle hemi-phalangectomy is performed. This is done because most patients complain of the kera-

totic lesion that overlies the PIPJ and therefore part of the middle phalanx. In most cases if a lateral middle hemi-

phalangectomy is not done only a portion of the keratotic lesion will disappear. To determine if enough of the mid-

dle phalanx has been removed one should palpate the remaining middle phalanx where the keratotic lesion is. If one

feels a depression then enough bone has been removed. If one presses and feels hard bone below then not enough

bone has been removed and more should be taken.

When evaluating a fifth toe is also important to inspect the lateral border of the fifth toenail. If there is a kera-

totic lesion or a thickening of the skin in that area, then at the time of surgery the keratotic skin and the underlying

bone should be removed.

Digital FusionsIndications

• Flexor substitution

• Extensor substitution

• Progressive neurological deformities

• Failed arthroplasty

• Flail toe

• Transverse IPJ deformity

Fusion Techniques• End to end arthrodesis-resection of the cartilage on each end of the joint down to subcondral bone. The joint

is then stabilized with a Kirschner wire, stainless steel wire, staple, screw, absorbable pin

• Peg-in-hoe arthrodesis-the head of the bone is denuded of its articular cartilage and then made into a peg

(pencil point) that is then inserted into a hole in the base. Any of the various fixation devices discussed in the

end-to end arthrodesis are then performed

• “V” arthrodesis-creating a “V” within the joint and then maintaining this position with any of the fixation

devices

Fusions of the appropriate joint(s) depends on whether you have a hammert oe, claw toe or mallet toe.

Lambrinudi procedure-fusion of the PIPJ & DIPJ for a claw toe.

Diaphasectomy-performed when there is a very long proximal phalanx. It is the removal of a portion of the

proximal phalanx. Not done often because the healing time is much longer then an arthroplasty.

Resection of the base of the proximal phalanx (mini-Keller) for toes 2, 3, 4, 5 should be avoided. It destabilizes

the MP joints and creates flail toes

Soft Tissue Surgery for Digital DeformitiesGeneral Indications

• Flexible deformity

• Adjunct to osseous procedures

• When performing digital surgery it is imperative to evaluate and treat the MPJ deformity

Soft Tissue Surgeries• Tenotomy-cutting of a tendon

• Tenectomy-cutting of a tendon but taking a section of the tendon out

• Extensor hood release-cutting the extensor expansion medially and laterally from the MPJ to the PIPJ


• Capsulotomy-cutting the MPJ capsule

• Tendon lengthening

• Tendon transfer

• Skin plasty

Skin incisions - done mostly for fifth toes to aid in its derotation - it is a teardrop incision (semi-elliptical) that

runs from distal medial to proximal lateral.

Extensor tenotomy - reduces MPJ contractures

Extensor hood Release - reduces MPJ contractures

Extensor lengthening - reduces MPJ contractures

Flexor tenotomy - reduces IPJ contractures

Capsulotomies - reduces MPJ contractures

Cutting of the collateral ligament and freeing the plantar plate at the MPJ - reduces MPJ contractures

Flexor tendon transfers-done with flexible deformities and reduces both the PIPJ & MPJ contractures. It is the

transfer of the FDL or FDB to the proximal phalanx. This reduces the IPJ deformity. When the flexor fires it reduces

the MPJ deformity.

Most of the soft tissue procedures that are performed are used to reduce the MPJ deformity. There are only two

soft tissue procedures written in the literature that are used by themselves to reduce completely flexible deformities.

One is a flexor tenotomy for a completely flexible mallet toe. The other is a flexor tendon transfer for a completely

reducible claw or hammertoe

Sequential Reduction of Hammer toes• Head resection

– Load the foot and see what happens to the MPJ- if it reduces completely then you are done if it does not

then

• Extensor hood release/extensor tendon lengthening

– Load the foot and see

• MPJ capsulotomy (this may include collateral ligament release and plantar plate release)


• Tendon transfer


• Arthrodesis of IPJ’s

If the MPJ’s do not reduce after performing the sequential reduction then you have a rigid MPJ, which should

be attacked by:

• Metatarsal head resection

• Shortening metatarsal osteotomy

Miscellaneous Digital Deformities

Helloma MolleHelloma Molle is a soft corn mostly found in the fourth interspace. It is not any corn that is found interdigital-

ly. If is only those macerated corns.

EtiologyRubbing of the head of the proximal phalanx of the fifth toe against the lateral base of the proximal phalanx of

the fourth toe (Fig. 6).


Figure 6.

Treatment

• Arthroplasty fifth toe

• Condylectomy fourth toe

• Arthroplasty fifth toe with condylectomy of the fourth toe

• Syndactyly - performed when prior procedures have failed, when there is a chronic draining ulcer, or the fifth

toe is flail

Clinodactyly - Deviated ToeClinodactyly is a transverse plane deformity at the PIPJ &/or DIPJ. The treatment for this deformity is either an

arthroplasty or arthrodesis at the affected joint(s). Arthrodesis seem to give better results.

Helloma DurumHelloma durum is a hard corn found along the medial or lateral aspects of the digits usually at the level of one

of the IPJ’s. Usually due to a hypertrophy of the bone at the level of the heloma durum.

TreatmentExcision of the hypertrophied bone using a burr, rasp, or rongeur.


Second MTPJ InstabilityDefinition: It is the imbalance of the functioning of both the intrinsic and extrinsic musculature, which eventu-

ally leads to MTPJ & IPJ deformities.

Synonyms: Cross Over Second Toe Deformity

Second MTPJ Dysfunction

Second MTPJ Stress Syndrome

Pre-dislocation Syndrome

Hammer Digit Syndrome

Etiology: Chronic synovitis/chronic capsulitis 2nd MTPJ

Chronic MTPJ hyperextension - high heeled shoes

Long 2nd metatarsal

Hallux Valgus

Hallux Interphalangeus

Chronic repetitive microtrauma to plantar plate

Pathology: Plantar plate attenuation or rupture

Lateral capsule/ligament attenuation or rupture

Rupture of first dorsal interossei tendon

Clincal Exam: Distal fat pad displacement

Keratotic lesions submetatarsal 2, PIPJ &/or DIPJ

Dorsal elevation/dislocation

Medial deviation

Tenderness dorsally & plantarly MTPJ

Edema dorsally & plantarly MTPJ

Clinical Tests: Lachman Test (Toe translation test, Dorsal draw test)

Toe held in 20-25 degrees dorsiflexion

Vertical translation of proximal phalanx

Positive test is two or more millimeters

Lachman Test Stages

Stage 0 – no dorsal translation of proximal phalanx

Stage 1 – subluxed but not dislocated

Stage 2 – phalangeal base can dislocate but is manually reduced

Stage 3 – phalangeal base is fixed in dislocated position

X-rays

Metatarsal length

Metatarsal morphology-large lateral condyle

Presence of Hallux Valgus and/or Hallux Interphalangeus

Transverse or sagittal plane deformities

Arthrogram

Extravasation of dye into flexor sheath

Plantar plate tear

MRI

Focal increase signal in torn plantar plate


Surgical Planning: Presence of hallux valgus

Presence of hallux interphalangeus

Flexibility/rigidity of second MTPJ

Transverse plane deformity of 2nd toe

Degree of instability of second MTPJ

Surgical Procedures: Hallux Valgus/Interphalangeus repair

Digital arthroplasty/arthrodesis

Sequential MTPJ reduction

Plantar plate release

Primary repair of plantar plate

Long or short flexor tendon transfer

Intrinsic (interosseous) tendon transfer

Decompression osteotomy 2nd metatarsal

Translational osteotomy 2nd metatarsal

second MTPJ arthroplasty

K wire stability

Durlacher’s CornDurlacher’s corn is a hyperkeratotic lesion found along the lateral aspect of the fifth toenail. Often seen with

PIPJ lesions of fifth toes but can be seen by itself.

TreatmentIf seen with PIPJ keratotic lesion perform an arthroplasty with lateral middle and lateral distal

hemiphalangectomies.

If seen by itself the skin lesion should be ellipsed out with two semi-elliptical longitudinal incisions and then

the bone removed with a burr, rongeur or rasp.

Overlapping Fifth Toes

Also known as:

• Digiti Quinti Varus

• Digiti Minimi Varus

Appearance• MPJ is dorsiflexed

• Toe is adducted

• Toe is in varus

Historical proceduresRuiz-Mora - large plantar elliptical skin wedge with excision of the entire proximal phalanx.

Butler - two racket shaped incisions completely encircling the toe and then an entire soft tissue release of the

extensor tendons and the fifth MPJ

Most of the time one sees these deformities in young children. They are usually not painful. The problem is that

they are embarrassed to take their shoes off especially when they are swimming or go to physical education in

school. The deformity as this time is usually flexible.


The procedure of choice for a flexible overlapping fifth toe is:

• “V’” to “Y” skin plasty

• EDL tenotomy

• Complete fifth MPJ capsulotomy

• Ruiz Mora plantar elliptical skin wedge

If one sees an overlapping fifth toe in an adult the deformity will probably not be flexible. If that is so then the

fifth MPJ may have to be reduced by either a fifth metatarsal head resection or a shortening fifth metatarsal osteoto-

my along with the “V” to “Y” skin plasty, the EDL tenotomy, and MPJ capsulotomy.

Hammered HalluxTreatmentArthroplasty-should not be done because it de-stabilizes the joint and on propulsion will cause the distal tip of

the toe to cock up.

• Arthrodesis-procedure of choice can be performed

– end to end

– peg and hole

• Fixation can be

– crossing K wires

– parallel K wires

– screws

• The EHL tendon is then brought proximally and placed into the capsule around the first metatarsal head

(Modified Jones suspension)

Pinch CallusPinch Callus is caused due to excessive pronation. Occurs at the plantar-medial aspect of the hallux at the IPJ.

Best treated with orthotics. If surgical intervention is decided then a medial approach is made and the plantar medi-

al aspect of the IPJ is removed using a rongeur, burr, osteotome and mallet, bone cutter, rasp.

IP Hallucal SesamoidIP Hallucal Sesamoid is seen in the plantar aspect of the hallux. The patient usually is complaining of a ker-

atoma plantarly at the IPJ. A lateral x-ray will reveal an accessory sesamoid at the level of the IPJ. A DP view will

reveal a radiodensity at the level of the IPJ. This sesamoid is found intracapsular. It is not found within the FDL ten-

don. There is some literature that says that there is a small slip of tendon in which the bone is encompassed thus

making it a true sesamoid bone. The bone does sit more toward the lateral aspect of the IPJ.

TreatmentThe surgical treatment is excision. There are four approaches:

• Plantar-easiest but for an unknown reason seed corns appear in the scar

• Lateral-gives best cosmetic result but technically difficult due to the second toe

• Medial is the most commonly done

• Dorsal-must open the IPJ to find bone. Too much dissection. Even though the sesamoid bone is not in the

FDL and is in the capsule, the FDL is close and one must take care not to sever it


Complications of Digital SurgeryChronic Edema

• Occurs usually due to:

– Lymphatic destruction

– Venous destruction

– Unequal digital length

Treatment• Elevation

• Compressive dressing

• Tube foam

• Tape

• Coban-Coflex

Angulational DeformitiesAngulational Deformities results in loss of stability on one or all planes. The transverse plane is most commonly

seen on the second toe.

Etiology• Adjacent digital deformity

• Poor dressing

TreatmentTake care not to place toes in a transverse plane position by placing dressing in between the toes. Use K wires

intra-operatively to keep toes straight. If big toe abuts up against the second toe pre-op then perform proper

osteotomy to correct hallux deformity

For second toes if the hallux is abutting may want to fuse the second regardless of the etiology

Sagittal Plane Deformity-Recurrence

Etiology• Inappropriate soft tissue procedure

• Inappropriate bony procedure

• Scar contraction

• Attacking the wrong joint

• Anterior fat pad migration

• Improper immobilization

• Wrong procedure (i.e. soft tissue for a rigid deformity)

Treatment• Proper preoperative evaluation

Frontal Plane deformityCombination of sagittal and transverse deformities

Treatment• Proper pre-operative evaluation

• Attacking the proper joint

• Performing the proper procedure

• Guide postoperative scarring


Transfer Lesions• Relative toe length - an excessively short toe can cause the adjacent long toe to be jammed in a shoe causing

hammering

• Doing a solo extensor tenotomy - Since the extensor tendon is one that divides into four, if one is cut it

increases the power of pull on the adjacent toe and may cause them to hammer.

• Doing one joint when the adjacent joint is in early disorder

• Doing one toe when the adjacent toe is already hammered but not as severe

Floating Toe SyndromeThe toe does not purchase the ground

Etiology• Anterior migration of the fat pad

• Metatarsal osteotomy

Control• Avoid a strict rectus toe

• Allow the toe to mold to the foot

Flail Toe/Telescoping ToeFlail toe is a condition in which there is no control. The toe is completely functionless. A functional problem

more then cosmetic. Telescoping toe-an extremely small toe. A cosmetic problem more then functional.

Etiology for Both• Excessive bone removal

• Overzealous deep tissue dissection

Treatment• Proper bony removal

• Proper soft tissue dissection

• Syndactyly

• Digital implant

IschemaIschema is caused by venous insufficiency or arterial insufficiency.

Protocol for Treatment of Postoperative Blue Toe Syndrome• Dependency

• Warm saline soaks

• Loosen dressing

• Heat to lower back

• Sympathetic block

• Loosen sutures

• Remove K wire (if used)

• Vasodilators

• Reverse epinephrin (if used)


NumbnessEtiology• Severance of nerve twigs-will see slow return

• Severance of digital nerve-will not see a return

The burning sensation is usually regeneration of nerve in a trapped scar.

Infection

Residual painResidual pain is most often due to scar tissue.

Excessive Shortening

Regeneration of Bone

Pseudarthrosis

Rigidity

Nail changes


chapter 6b digital surgery

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