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

Hammertoes: Anatomy, Pathophysiology, and Comprehensive Treatment Strategies

Hammertoe is a common foot deformity that originates from the proximal interphalangeal joint of the lesser toes. The deformity involves an imbalance between the muscles and tendons that control toe movement, leading to deformity. Hammertoes can result from various factors, including genetic predisposition, ill-fitting footwear, trauma, or underlying medical conditions such as neuromuscular disorders or diabetic neuropathy. As the deformity progresses, patients may experience pain, difficulty walking, and development of corns or calluses on the affected toes. Treatment strategies for hammertoes range from nonsurgical to surgical, depending on the severity of discomfort and effect on patient function. Nonsurgical treatment includes wearing appropriate footwear, using orthotic devices, and performing targeted exercises to strengthen and stretch affected muscles. In more advanced cases, surgical options, such as tendon transfers, joint arthrodesis, or arthroplasty, may be considered. A comprehensive understanding of hammertoe anatomy, pathophysiology, and treatment options is crucial for the effective management of this condition.

Rheumatoid Deformities of the Lesser Toes

Rheumatoid arthritis is a chronic heterogeneous autoimmune disease characterized by painful joint inflammation and causes destructive bone erosions. Most common deformities in the rheumatoid forefoot are hallux valgus and claw toes. Radiographs are helpful to show the deformity and the associated pathologies. Nonsurgical treatment is focused on pain reduction, function preservation, and prevention of further deformity, by relieving pressure and pain with shoe modification and use of insoles. Surgical procedures can address either soft tissue and bone deformities that can be performed by a percutaneous or open approach.

Minimally Invasive Alternatives for the Treatment of Lesser Toe Deformities

Toe deformities are often correct with a simple proximal interphalangeal joint fusion whatever if the joint is mobile or rigid. Percutaneous technique allows a different approach of the deformity. Fusion is no more the only solution. This article shows the different procedure that can be done percutaneously. Like all technique, it needs a specific training.

Comparative analysis of bone consolidation chronology in claw toes operated through minimal invasive osteotomies in diabetic vs. non-diabetic patients

Objective

To compare bone healing time in osteotomies performed in claw toes correction through minimal invasive surgery in diabetic vs. non-diabetic patients. The relation between the patient's ages and the American Orthopedic Foot and Ankle Surgery Society (AOFAS) functional scores before and after surgery was also analyze in the two types of patients.

Method

A series of 45 women, 23 of them suffering from Diabetes Mellitus, were operated to correct claw toes. The surgery was always performed through minimal invasive digital osteotomies. After the intervention, bone healing was controlled by a fluoroscopic weekly follow-up until a complete bone consolidation was reached. Bone healing time was compared in in two groups of patients, diabetic and non-diabetic. All patients were evaluated with AOFAS scale 48 h before and 90 days after the intervention.

Results

The time of bone healing ranged from 24 to 40 days after the surgery and took shorter time of consolidation in non-diabetic patients although the Mann Withney U test did not show statistically significant differences (p = 0,409, effect size (ES) = 0,14 [-0.20 to 0.45]) between both groups. A statistically significant association (r = 0.71, R ²= 50%, p < 0.001) was found between the healing days and the day of medical discharge, also between the ages of the patients and the medial discharge (r = 0.36, R ²= 13%, p < 0.001). However, no statistically significant associations were found between pre-intervention glycemia and days of bone consolidation, neither in medical discharge (r = 0.07, p = 0.646 y r = 0.07, p = 0.648, respectively). AOFAS test scores and the diabetes status showed statistically significant differences, both in the main effect of Diabetes (F_[1,41]= 9.41, p = 0.004) as in the interaction between diabetes and age (F_[1,41]= 9.17, p = 0.004).

Conclusions

The bone healing time in claw toes operated through minimal invasive osteotomy surgery is not influenced by the presence of diabetes. The consolidation speed and the improvement in AOFAS functional scale score post-surgery in diabetic and elder patients was related to duration of the medical discharge.

Percutaneous flexor digitorum brevis tenotomy: An anatomical study

INTRODUCTION

A percutaneous selective flexor digitorum brevis (FDB) tenotomy and a proximal interphalangeal (PIP) joint arthrolysis may correct a lesser claw toe deformity keeping flexor digitorum longus (FDL) and active flexion. Our study aimed to verify if the procedure was effective and reliable and if it respects the surrounding soft tissues.

MATERIAL AND METHOD

Twelve cadaveric lateral toes were used. A dissection ensured the integrity of both digital nerves, FDL and flexor pulleys and assessed the section of both FDB slips and PIP arthrolysis.

RESULTS

A complete section of the two FDB slips was observed in 4 cases (33%). Arthrolysis was achieved in all cases. Surrounding soft tissues were found intact in all cases.

CONCLUSION

This procedure is effective regarding PIP arthrolysis, but a technical improvement is required to achieve a reliable section of both FDB slips. In the hands of an experienced surgeon, it has proven to be safe.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Minimally Invasive Advances: Lesser Toes Deformities

Minimally invasive procedures to treat lesser toes deformities are among the main surgeries of percutaneous techniques and considered mature techniques due to technical versatility and high correction potential, with low rates of complications. Although they seem technically simple procedures, there are important technical details for each of them to obtain a reliable correction. To achieve success in lesser toes percutaneous treatment, it is imperative to follow minimally invasive basic principles, especially postoperative care with specific bandages for unfixed osteotomies. Practical training is mandatory before starting the experience; the foot surgeon must learn theoretic and practical aspects to master this surgery.

The impact of associated tenotomies on the outcome of incomplete phalangeal osteotomies for lesser toe deformities

BACKGROUND

Partial or incomplete osteotomy (IO) of the phalanx is recently described in the literature. However, the clinical outcome and the rate of complications when applied to lesser toe deformities (LTD) have been never addressed. This study aims to find out if the association of tenotomies to incomplete or partial phalanx osteotomies has a significant impact on the clinical outcomes, the occurrence of complications, and the recovery time after surgery.

METHODS

A retrospective review of two cohorts of cases operated in our institution for hallux abductus valgus (HAV) and associated LTD from 2008 to 2014 was carried out. The surgical correction of both HAV and the associated LTD was always performed by minimally invasive techniques. The study included a total of 223 patients (723 IO in 556 toes). In 129 cases, the IO for LTD correction was performed without tenotomies, and in 94, the procedure was combined with flexor and/or extensor tenotomies. Patients were assessed with the American Orthopaedic Foot and Ankle Society (AOFAS) questionnaire before surgery and at 6- and 12-month follow-up.

RESULTS

The mean preoperative AOFAS score before surgery was similar in both cohorts. At 12-month follow-up, the cohort without tenotomies showed better recovery (95.7 ± 2.8 versus 92.5 ± 6.8; p < 0.01). AOFAS scores decreased as the number of associated LTD increased (r = - 0.814; p < 0.001). Cases operated on by PO + tenotomy showed a high rate of complications such as delayed union of the osteotomy (p < 0.01), hypertrophic callus (p < 0.01), phalangeal fracture at the osteotomy site (p < 0.01), and lack of correction (p < 0.05). The overall occurrence of adverse events was 38.6% in cases operated by PO + tenotomy and 13.9% in cases receiving PO alone (p < 0.0001). Cases operated on without tenotomy showed a shorter time to complete recovery for daily life activities (37.4 ± 2.3 versus 43.0 ± 1.7 days; p < 0.01).

CONCLUSION

The performance of associated tenotomies to incomplete phalanx osteotomies provides worse clinical outcomes, higher complication rates, and longer recovery time as compared to similar forefoot surgeries without tenotomies.

TRIAL REGISTRATION

The study was based on retrospectively registered data starting on May 24, 2008.

Treatment of Flexible Lesser Toe Deformities

Lesser toe deformities are among the most common complaints presented to foot and ankle specialists. These deformities present in variable ways, which makes surgical decision making complex. For every type of deformity, there could be a combination of soft tissues and bony procedures, chosen according to the surgeon's preferences. This article first describes modern classification of lesser toe deformities, and then presents the different treatments and procedures available for those flexible deformities. In addition, this article proposes an algorithm based on clinical/radiological evaluation and step-by-step surgical decision making.

Managing Complications of Lesser Toe and Metatarsophalangeal Joint Surgery

The anatomy of the lesser toes is highly complicated and not yet well understood. The high propensity of the metatarsophalangeal joint to develop hyperextension deformity should be recognized. Surgeons should provide each patient with a realistic expectation for lesser toe reconstructive procedures. A successful surgical result requires a well-planned procedure, accurate execution using proper techniques, and meticulous postoperative care. When complications occur, surgeons should identify culprits so that proper treatment strategies can be successfully executed. This article discusses a wide array of tactics to manage common complications in lesser toe surgery.