digital surgery complications - asps · •revision of failed foot surgery: a critical analysis...
TRANSCRIPT
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Digital Surgery Complications
Zeeshan S. Husain, DPM, FACFAS, FASPSGreat Lakes Foot and Ankle Institute
September 21, 2018
Annual Surgical Conference 2018
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Disclosures
• None
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Presentation Outline
• Differentials– Neuroma– Plantar plate injury– Metatarsalgia– Hammertoe
• Influencing factors– Anatomy
• Hammertoe• Rigidity• Plane(s) of deformity
• Complications
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Presentation Outline
• Differentials– Neuroma– Plantar plate injury– Metatarsalgia– Hammertoe
• Influencing factors– Anatomy
• Hammertoe• Rigidity• Plane(s) of deformity
• Complications
• Treatment options– Arthrodesis– Tendon transfers
• Flexor tenotomy• Girdlestone-Taylor
– Variations
• EDB transfer• Hibbs
• What have I learned?– Arthroplasty needs to be
retired
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Plantar Plate
• Subjective– “Walking on pebble”– Wart under foot– Pain
• Under MPJ• MPJ effusion
• Biomechanical– Hammertoe– Hallux abductovalgus– Elongated 2nd metatarsal1
– Equinus
• Iatrogenic– Steroid2
1. Klein, et al, Foot Ankle Spec 6:2, 2013.
2. Reis, et al., J Bone Joint Surg 71B:5, 1989.
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Differential Diagnoses
• Misdiagnosis– Capsulitis / Synovitis– Freiberg’s disease– Arthritides– Stress fracture– Neuroma1
• Single 97/279
– 3rd interspace 74.2%
• Multiple 182/279
– 2nd interspace 98.9%– 3rd interspace 100.0%
1. Valero, et al., J Foot Ankle Surg 54:3, 2015.
2nd MPJ plantar exposure
2nd IMS neuroma
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The Plantar Plate
• Plantar plate function– Stabilize MPJ with lumbricales
and FDL– Resists DF tensile forces– Offers gliding surface for flexor
tendons– Weakest at base of phalanx1
– Assists Windlass mechanism
• Lachman test– DF toe at 25°– Translate dorsally / plantarly
1. Jolly, in Master Techniques in Podiatric Surgery: The Foot and Ankle, ed. Chang, Lippincott,
Williams and Wilkins, Philadelphia, 2005.
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Staging MPJ Instability
• Stage 1– Subtle edema with pain to plantar MPJ– Most (70-90%) alleviate in several days
• Stage 2– Moderate edema– Radiographic deviation of digit– Loss of toe purchase– Poor response to conservative treatment
• Stage 3– Moderate edema– Frank subluxation/dislocation– Often seen with HAV deformity– Rarely responds to conservative treatment
Yu and Judge, in Reconstructive Surgery of Foot and Leg, editors Camasta, et al., Podiatry
Institute Publishing, pp109-13, 1995.
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Staging MPJ Instability
• Grade 0- No instability– No joint pain, thickening, or swelling
– Prodromal phase but no deformity
• Grade 1- Mild instability– Synovitis and mild deviation
– Positive drawer sign without significant deformity
• Grade 2- Moderate instability– Dorsomedial deviation/subluxation
– Positive drawer sign with deformity
• Grade 3- Dislocated MPJ– Positive drawer sign with cross-over deformity
• Grade 4- Rigid dislocated MPJ
Haddad, et al., Foot Ankle Int 20:12, 1999.
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Imaging
• Radiographs
• Ultrasound• Dynamic
• Arthrogram
• MRI
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Imaging
• Radiographs
• Ultrasound• Dynamic
• Arthrogram
• MRIMTH
Base of
phalanx
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Imaging
• Radiographs
• Ultrasound• Dynamic
• Arthrogram
• MRI
Normal plantar plate
MTH
Base of
phalanx
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Imaging
• Radiographs
• Ultrasound• Dynamic
• Arthrogram
• MRI
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Imaging
• Radiographs
• Ultrasound• Dynamic
• Arthrogram
• MRI
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Imaging
• Radiographs
• Ultrasound• Dynamic
• Arthrogram
• MRI
Yao, et al., Am J Roentgenol 163:3, 1994.
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Imaging
• Radiographs
• Ultrasound• Dynamic
• Arthrogram
• MRI
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Hammertoe Complications
• Reproducibility– Predictable results
• Arthrodesis
– Retire the arthroplasty
• Typical complications– Incision contracture– Prolonged swelling– Floating toe– Poor purchase– Deviated toe if
performing arthroplasty– Issues with K-wires
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Hammertoe Complications
• Proposed algorithm– Rigid?
• PIPJ arthrodesis
– Flexible?• Restore MPJ and PIPJ
congruency with tendon transfer(s)
– Goals• Restore FDL function• Joint congruency• Correct transverse plane
deformity
• Reproducibility– Predictable results
• Arthrodesis
– Retire the arthroplasty
• Typical complications– Incision contracture– Prolonged swelling– Floating toe– Poor purchase– Deviated toe if
performing arthroplasty– Issues with K-wires
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Literature
• Revision of failed foot surgery: a critical analysis– n = 244
– Most common reason for revision• Transfer metatarsalgia• Recurrent bunion• Lesser digit deformity
– Satisfaction rates after revision• Revisions- 176/244• 24% with reservations• 6% dissatisfied
Kilmartin, J Foot Ankle Surg 41:5, 2002.
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Literature
• Complications of digital and lesser metatarsal surgery– Risk factors and co-morbidities
– Wound healing and infectious complications
– Smoking
– Implant failure and management
– Acute digital correction of longstanding toe deformities
– AVN of lesser metatarsals following surgery
– Floating and flail toe deformity
Bibbo, et al., Clin Podiatr Med Surg 27:4, 2010.
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Distal Metatarsal Osteotomy
• Indications– Metatarsalgia– Metatarsal parabola– Plantar plate techniques
• Floating toe rates– Migues, et al.
• Incidence– Osteotomy alone 28.5%– With digital correction 50.0%
– Highlander, et al.• Incidence
– Floating toe 36.0%
Migues, et al., Foot Ankle Int 25:9, 2004.
Highlander, et al., Foot Ankle Spec 4:3, 2011.
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Malposition
• Considerations– Level of deformity– Influence of adjacent
digits– Osseous versus soft
tissue
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Optimizing Results
• Recognizing pathology– Anatomy
– Plantar plate injury?
– Rigidity
– Plane(s) of deformity
• Predictable outcomes– Arthrodesis
– Tendon transfers• FDL
• EDB
Trethowan, Lancet 205:5312, 1925.
Taylor, J Bone Joint Surg 33B, 1951.
Forrester-Brown, J Bone Joint Surg 20A:1,
1938.
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• Direct plantar approach
Case Scenario- Plantar Plate
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• Dorsal surgical approach
– Metatarsal osteotomy
– Plantar plate exposure
– Suture plantar plate
– Phalanx suture tunnels
– Tension repair
– Metatarsal fixation
Case Scenario- Plantar Plate
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Case Scenario- Plantar Plate
• Dorsal surgical approach
– Metatarsal osteotomy
– Plantar plate exposure
– Suture plantar plate
– Phalanx suture tunnels
– Tension repair
– Metatarsal fixation
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Case Scenario- Plantar Plate
• Dorsal surgical approach
– Metatarsal osteotomy
– Plantar plate exposure
– Suture plantar plate
– Phalanx suture tunnels
– Tension repair
– Metatarsal fixation
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Case Scenario- Plantar Plate
• Dorsal surgical approach
– Metatarsal osteotomy
– Plantar plate exposure
– Suture plantar plate
– Phalanx suture tunnels
– Tension repair
– Metatarsal fixation
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Case Scenario- Plantar Plate
• Dorsal surgical approach
– Metatarsal osteotomy
– Plantar plate exposure
– Suture plantar plate
– Phalanx suture tunnels
– Tension repair
– Metatarsal fixation
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Case Scenario- Plantar Plate
• Dorsal surgical approach
– Metatarsal osteotomy
– Plantar plate exposure
– Suture plantar plate
– Phalanx suture tunnels
– Tension repair
– Metatarsal fixation
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Case Scenario- Plantar Plate
• Dorsal surgical approach
– Metatarsal osteotomy
– Plantar plate exposure
– Suture plantar plate
– Phalanx suture tunnels
– Tension repair
– Metatarsal fixation
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Case Scenario- Plantar Plate
• What did I do?– Repaired attenuated ligament– Will it hold?
• Alternative– FDL tendon transfer
Reinforce correction with steri-strips
Pre-op
Post-op
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Case Scenario- FDL Transfer
• Surgical approach
– PIPJ preparation
– FDL tendon
– Bone tunnel
– Tension tendon
– Bone anchor
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Case Scenario- FDL Transfer
• Surgical approach
– PIPJ preparation
– FDL tendon
– Bone tunnel
– Tension tendon
– Bone anchor
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Case Scenario- FDL Transfer
• Surgical approach
– PIPJ preparation
– FDL tendon
– Bone tunnel
– Tension tendon
– Bone anchor
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Case Scenario- FDL Transfer
• Surgical approach
– PIPJ preparation
– FDL tendon
– Bone tunnel
– Tension tendon
– Bone anchor
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Case Scenario- FDL Transfer
• Surgical approach
– PIPJ preparation
– FDL tendon
– Bone tunnel
– Tension tendon
– Bone anchor
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Case Scenario- FDL Transfer
• Surgical approach
– PIPJ preparation
– FDL tendon
– Bone tunnel
– Tension tendon
– Bone anchor
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Case Scenario- FDL Transfer
• Surgical approach
– PIPJ preparation
– FDL tendon
– Bone tunnel
– Tension tendon
– Bone anchor
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Case Scenario- EDB Transfer
1
• Surgical approach
– Metatarsal bone tunnel• Pass suture under
deep intermetatarsal ligament
– Proximal phalanx bone tunnel
– Adjust tension
* Downey, et al., in McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery,
ed. Southerland, et al., Lippincott, Williams and Wilkins, Philadephia, 2013.
*
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Case Scenario- EDB Transfer
1
• Surgical approach
– Metatarsal bone tunnel• Pass suture under
deep intermetatarsal ligament
– Proximal phalanx bone tunnel
– Adjust tension
* Downey, et al., in McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery,
ed. Southerland, et al., Lippincott, Williams and Wilkins, Philadephia, 2013.
*
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Case Scenario- EDB Transfer
• Surgical approach
– Metatarsal bone tunnel• Pass suture under
deep intermetatarsal ligament
– Proximal phalanx bone tunnel
– Adjust tension
2
* Downey, et al., in McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery,
ed. Southerland, et al., Lippincott, Williams and Wilkins, Philadephia, 2013.
*
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Case Scenario- EDB Transfer
• Surgical approach
– Metatarsal bone tunnel• Pass suture under
deep intermetatarsal ligament
– Proximal phalanx bone tunnel
– Adjust tension
3
* Downey, et al., in McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery,
ed. Southerland, et al., Lippincott, Williams and Wilkins, Philadephia, 2013.
*
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Case Scenario- EDB Transfer
• Surgical approach
– Metatarsal bone tunnel• Pass suture under
deep intermetatarsal ligament
– Proximal phalanx bone tunnel
– Adjust tension
* Downey, et al., in McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery,
ed. Southerland, et al., Lippincott, Williams and Wilkins, Philadephia, 2013.
*
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Post-operatively
• Cicatrix contracture
• Splintage– K-wire– Bandaging– Taping– Splinting
• Weightbearing status– Surgical shoe
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Conclusions
• Accurate diagnosis– Determine deforming
factors
• Balance expectations
• Be definitive on surgical procedures– Arthrodesis– Tendon transfers