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Mens M, Busch-Westbroek T, Bus S, van Netten J, Wellenberg R, Streekstra G, Maas M, Nieuwdorp M, Kerkhoffs G, Stufkens S. The efficacy of flexor tenotomy to prevent recurrent diabetic foot ulcers (DIAFLEX trial): Study protocol for a randomized controlled trial. Contemp Clin Trials Commun 2023; 33:101107. [PMID: 36950303 PMCID: PMC10027496 DOI: 10.1016/j.conctc.2023.101107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 02/21/2023] [Accepted: 03/10/2023] [Indexed: 03/12/2023] Open
Abstract
Foot ulcers are a frequent and costly problem in people with diabetes mellitus and can lead to amputations. Prevention of these ulcers is therefore of paramount importance. Claw/hammer toe deformities are commonly seen in people with diabetes. These deformities increase the risk of ulcer development specifically at the (tip of) the toe. Percutaneous needle tenotomy of the tendon of the m. flexor digitorum longus (tendon tenotomy) can be used to reduce the severity of claw/hammer toe deformity with the goal to prevent ulcer recurrence. The main objective of this randomized controlled trial is to assess the efficacy of flexor tenotomy to prevent recurrence of toe ulcers in people with diabetes and a history of toe (pre-)ulcers. Additionally, we aim to assess interphalangeal joints (IPJ) and metatarsophalangeal joint (MTPJ) angles in a weight-bearing and non-weight-bearing position, barefoot plantar pressure during walking, cost-effectiveness and quality of life before and after the intervention and compare intervention and control study groups. Sixty-six subjects with diabetes and claw/hammer toe deformity and a recent history of (pre-)ulceration on the tip of the toe will be included and randomized between flexor tenotomy of claw/hammer toes (intervention) versus standard of care including orthosis and shoe offloading (controls) in a mono-center randomized controlled trial. Clinicaltrialsgov registration NCT05228340.
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Key Words
- CBCT, Cone-Beam Computed Tomography
- DIPJ, Distal Interphalangeal Joint
- DM, Diabetes Mellitus
- Flexor tenotomy
- Foot ulcer
- IPJ, Interphalangeal Joint
- MTPJ, Metatarsal Phalangeal Joint
- PIPJ, Proximal Interphalangeal Joint
- Prevention
- RCT, Randomized Controlled Trial
- ROI, Region Of Interest
- SD, Standard Deviation
- SF-36, Short-Form-36
- Toe deformity
- WTBCT, Weight-Bearing CT
- μSv, Microsievert
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Affiliation(s)
- M.A. Mens
- Amsterdam UMC, Location University of Amsterdam, Radiology and Nuclear Medicine, Meibergdreef 9, Amsterdam, the Netherlands
- Amsterdam Movement Sciences, Rehabilitation and Development, Amsterdam, the Netherlands
- Corresponding author. Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.
| | - T.E. Busch-Westbroek
- Amsterdam UMC, Location University of Amsterdam, Rehabilitation Medicine, Meibergdreef 9, Amsterdam, the Netherlands
- Amsterdam Movement Sciences, Rehabilitation and Development, Amsterdam, the Netherlands
| | - S.A. Bus
- Amsterdam UMC, Location University of Amsterdam, Rehabilitation Medicine, Meibergdreef 9, Amsterdam, the Netherlands
- Amsterdam Movement Sciences, Rehabilitation and Development, Amsterdam, the Netherlands
| | - J.J. van Netten
- Amsterdam UMC, Location University of Amsterdam, Rehabilitation Medicine, Meibergdreef 9, Amsterdam, the Netherlands
- Amsterdam Movement Sciences, Rehabilitation and Development, Amsterdam, the Netherlands
| | - R.H.H. Wellenberg
- Amsterdam UMC, Location University of Amsterdam, Radiology and Nuclear Medicine, Meibergdreef 9, Amsterdam, the Netherlands
- Amsterdam Movement Sciences, Rehabilitation and Development, Amsterdam, the Netherlands
| | - G.J. Streekstra
- Amsterdam UMC, Location University of Amsterdam, Biomedical Engineering and Physics, Meibergdreef 9, Amsterdam, the Netherlands
- Amsterdam Movement Sciences, Rehabilitation and Development, Amsterdam, the Netherlands
| | - M. Maas
- Amsterdam UMC, Location University of Amsterdam, Radiology and Nuclear Medicine, Meibergdreef 9, Amsterdam, the Netherlands
- Amsterdam Movement Sciences, Rehabilitation and Development, Amsterdam, the Netherlands
| | - M. Nieuwdorp
- Amsterdam UMC, Location University of Amsterdam, Internal Medicine, Meibergdreef 9, Amsterdam, the Netherlands
- Amsterdam Cardiovascular Sciences, Diabetes and Metabolism, Amsterdam, the Netherlands
| | - G.M.M.J. Kerkhoffs
- Amsterdam UMC, Location University of Amsterdam, Orthopaedic Surgery, Meibergdreef 9, Amsterdam, the Netherlands
- Amsterdam Movement Sciences, Rehabilitation and Development, Amsterdam, the Netherlands
| | - S.A.S. Stufkens
- Amsterdam UMC, Location University of Amsterdam, Orthopaedic Surgery, Meibergdreef 9, Amsterdam, the Netherlands
- Amsterdam Movement Sciences, Rehabilitation and Development, Amsterdam, the Netherlands
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de Cesar Netto C, Schmidt EL, Lalevee M, Mansur NSB. Flexor tenodesis procedure in the treatment of lesser toe deformities. Arch Orthop Trauma Surg 2022; 142:3125-37. [PMID: 33974142 DOI: 10.1007/s00402-021-03942-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 05/03/2021] [Indexed: 11/16/2022]
Abstract
In this technical report study, we describe the use of a flexor tenodesis procedure in the treatment of lesser toe deformities (LTD). Using a specific implant, both the flexor digitorum longus and brevis tendons are attached to the plantar aspect of the proximal phalanx, allowing dynamic correction of flexible deformities of metatarsophalangeal and interphalangeal joints. Good clinical results and absence of complications were observed in a series of 3 patients, with considerable correction of the LTD, and absence of substantial residual floating toe or metatarsophalangeal joint stiffness. LEVEL OF EVIDENCE: V - Technical Report/Case Report/Expert Opinion.
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Xiao F, Yang Y. [Research progress of interphalangeal arthrodesis]. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2020; 34:1195-1199. [PMID: 32929916 DOI: 10.7507/1002-1892.201910093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To review the research progress of interphalangeal arthrodesis in the treatment of interphalangeal joint deformity. Methods The literature about interphalangeal arthrodesis at home and abroad was extensively consulted, and the indications, fusion methods, fixation methods, complications, and so on were summarized and analysed. Results The indications of interphalangeal arthrodesis are hammer toe, claw toe, and mallet toe. From the different forms of fusion surface, fusion methods include end-to-end, peg-in-hole, conical reamer type, and V-shape arthrodesis. There are three kinds of fixation methods: Kirschner wire fixation, stainless-steel wire suture fixation, and intramedullary fixation, and there are many kinds of intramedullary fixation. The complications of interphalangeal arthrodesis include vascular injury, fixation related complications, and postoperative complications. Conclusion Interphalangeal arthrodesis is a good way to correct some deformities of toes, but the incidence of various complications can not be ignored, and there is still a lack of clinical research on interphalangeal arthrodesis.
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Affiliation(s)
- Fajiao Xiao
- Department of Ankle Surgery, Tongji Hospital of Tongji University, Shanghai, 200065, P.R.China
| | - Yunfeng Yang
- Department of Ankle Surgery, Tongji Hospital of Tongji University, Shanghai, 200065, P.R.China
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Abstract
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.
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Affiliation(s)
- Guillaume Cordier
- Clinique du Sport Bordeaux-Mérignac, France; GRECMIP-MIFAS (Groupe de Recherche en Chirurgie Mini-Invasive du Pied-Minimally Invasive Foot and Ankle Society), 2 rue Negrevergne, Merignac 33700, France.
| | - Gustavo Araujo Nunes
- GRECMIP-MIFAS (Groupe de Recherche en Chirurgie Mini-Invasive du Pied-Minimally Invasive Foot and Ankle Society), 2 rue Negrevergne, Merignac 33700, France; Hospital Ortopédico, Belo Horizonte, Minas Gerais, Brazil
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Lintz F, Beldame J, Kerhousse G, Bernasconi A, Brunel H, Darcel V, Helix-Giordanino M, Piclet-Legré B. Intra- and inter-observer reliability of the AFCP classification for sagittal plane deformities of the second toe. Foot Ankle Surg 2020; 26:650-656. [PMID: 31522870 DOI: 10.1016/j.fas.2019.08.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 08/04/2019] [Accepted: 08/15/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND The French Association of Foot Surgery (AFCP) recently proposed a morphological classification of lesser toe deformities, describing the position of each joint (metatarsophalangeal or MTP, proximal interphalangeal or PIP and distal interphalangeal or DIP) in relation to their anatomic position in the sagittal plane. A study was designed to test its reliability for assessment of sagittal plane deformities of the second toe. METHODS In this retrospective study 55 toes (55 feet, 50 patients) were evaluated. Eleven foot and ankle surgeons assessed independently standardized photographs of each case acquired in a blinded fashion. Assessment was repeated three times, each 15 days apart. Intra- (Intraclass Correlation Coefficient or ICC) and inter-observer reliability (Fleiss' Kappa coefficient) were calculated for each joint. RESULTS Intra- and inter-observer reliability were moderate for the MTP joint (ICC range, 0.54-0.61) (Kappa range, 0.53-0.61) and substantial for the PIP (ICC range, 0.60-0.71) (Kappa range, 0.68-0.75) and DIP joints (ICC range, 0.69-0.78) (Kappa range, 0.74-0.78). Mean assessment time±standard deviation was 35±10s per case. CONCLUSIONS The AFCP classification proved itself reliable in the assessment of sagittal plane defomities of the second toe among eleven foot and ankle surgeons. It is based only on a visual description of the deformity, and does not provide informations on either the clinical reducibility of the deformity and the radiographic joint status. LEVEL OF EVIDENCE Level IV, retrospective cohort study.
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Affiliation(s)
- François Lintz
- Clinique de l'Union, Ankle and Foot Surgery Center, Saint-Jean, France.
| | | | | | - Alessio Bernasconi
- Foot and Ankle Unit, Royal National Orthopaedic Hospital, Stanmore, United Kingdom; Department of Public Health, "Federico II" Naples University, Orthopaedic and Traumatology Unit, Napoli, Italy
| | - Helena Brunel
- Institut de Formation en Masso-Kinésithérapie "Saint-Michel", Paris, France
| | - Véronique Darcel
- Maison de Santé Protestante de Bordeaux Bagatelle, Talence, France
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Yassin M, Bowirat A, Robinson D. Percutaneous surgery of the forefoot compared with open technique - Functional results, complications and patient satisfaction. Foot Ankle Surg 2020; 26:156-62. [PMID: 30737141 DOI: 10.1016/j.fas.2019.01.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 11/30/2018] [Accepted: 01/14/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND The use of percutaneous surgery is currently very common in foot and ankle surgery. The following prospective open-label patient-preference based study compares the traditional open technique versus the percutaneous surgery technique. METHODS The current study describes the results of 287 patients operated due to forefoot deformities either by open surgery or percutaneously. 96 of them underwent hallux valgus corrective surgery. The rest had lesser toe deformities. They were followed for a period of up to 24 months, to assess the surgery related pain, complications, and patient satisfaction. 112 patients were operated using a conventional open technique were compared to 175 patients treated using a percutaneous technique. Technique choice was left to the patient preference, though older patients with disturbed blood flow, were advised to undergo percutaneous surgery. RESULTS There is less pain using the percutaneous techniques relative to the open technique during the first 6 post-operative weeks. The 6, and 24 months FAOS score is similar in both groups. Complications are rare in any of the groups, with a significantly higher ASEPSIS score in the open surgery group. CONDCLUSIONS Percutaneous forefoot surgery appears safe and efficacious, demonstrating equal radiographic (in a 96 strong cohort of hallux valgus patients) and clinical results at six and 24 months. Due to less post-operative pain, and less infection risk it appears that percutaneous techniques are superior to open technique in some respects of treatment and indeed the PGIC of patients was significantly higher in this group.
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Sarikaya IA, Seker A, Erdal OA, Talmac MA, Inan M. Surgical correction of hallux valgus deformity in children with cerebral palsy. Acta Orthop Traumatol Turc 2018; 52:174-178. [PMID: 29478778 PMCID: PMC6136310 DOI: 10.1016/j.aott.2018.01.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 07/30/2017] [Accepted: 01/29/2018] [Indexed: 11/30/2022]
Abstract
Objective This study aimed to present a treatment algorithm for the correction of the hallux valgus deformity in Cerebral Palsy (CP) patients and to discuss the outcomes based on our clinical and radiological results. Methods 29 patients (45 feet) were included in the study. The mean age of the patients at the time of the surgery was 14 (range 6–22) years. The mean follow-up was 33 (range 22–59) months. A reconstructive procedure was performed on 19 patients (27 feet); a soft tissue surgery and exostectomy of the bunion in six patients (11 feet); and MTP joint arthrodesis in four patients (7 feet). The hallux valgus angle (HVA) and the anteroposterior intermetatarsal angle (IMA) were used for radiologic evaluation and the DuPont Bunion Rating Score was used for clinical evaluation. Results The follow-up period was 36 (range 22–59) months in reconstructive group, 27 (range 24–29) months in soft tissue group, and 29 (range 23–41) months in MTP arthrodesis group. Significant improvements were detected in hallux valgus angle in three groups postoperatively but in soft tissue group correction loss was observed during follow up. Best results were achieved in arthrodesis group and worse in soft tissue group in terms of clinical evaluation. Conclusion According to our results isolated soft tissue procedures are ineffective in CP patients. Soft tissue procedure combined with metatarsal osteotomy has satisfactory results. Level of evidence Level IV, therapeutic study.
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Affiliation(s)
| | - Ali Seker
- Istanbul Medipol University Department of Orthopaedics and Traumatology, Istanbul, Turkey
| | | | - Mehmet Ali Talmac
- Sisli Etfal Training and Research Hospital, Orthopaedics and Traumatology Clinic, Istanbul, Turkey
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Abstract
BACKGROUND Metatarsophalangeal joint instability of the lesser toe can cause acquired toe deformity. Plantar plate deficiency is the major pathology. Plantar plate repair can stabilize the joint but may result in iatrogenic transverse plane toe deformity in correction of claw toe deformity. Limited toe extension can be resulted after correction of crossover toe deformity by plantar plate tenodesis and extensor digitorum brevis transfer. A modification of the technique is proposed. MATERIALS AND METHODS The clinical outcomes of 10 patients with the modified procedure performed were assessed. RESULTS The correction was full in all toes with no recurrence. CONCLUSION The modified technique can stabilize the metatarsophalangeal joint and correct lesser toe deformity without the need of tendon transfer, osteotomy or sophisticated instrumentation.
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Affiliation(s)
- T H Lui
- Department of Orthopaedics and Traumatology, North District Hospital, 9 Po Kin Road, Sheung Shui, NT, Hong Kong Special Administrative Region.
| | - L L LiYeung
- Department of Orthopaedics and Traumatology, North District Hospital, 9 Po Kin Road, Sheung Shui, NT, Hong Kong Special Administrative Region.
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Scott JE, Hendry GJ, Locke J. Effectiveness of percutaneous flexor tenotomies for the management and prevention of recurrence of diabetic toe ulcers: a systematic review. J Foot Ankle Res 2016; 9:25. [PMID: 27478505 PMCID: PMC4966795 DOI: 10.1186/s13047-016-0159-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Accepted: 07/26/2016] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Diabetic toe ulcers are a potentially devastating complication of diabetes. In recent years, the percutaneous flexor tenotomy procedure for the correction of flexible claw and hammer-toe contraction deformities has been proposed as a safe and effective technique for facilitating the healing of toe-deformity related diabetic ulcers. The aim of this review is to critically appraise the evidence for the effectiveness of this surgical procedure in achieving ulcer healing, prevention of re-ulceration, and to summarise the rate of post-operative complications. METHOD A search of medical databases, was performed to locate relevant literature. Titles were screened prior to abstract and full text review to identify articles relevant to the research question. Search terms included truncations of "tenotomy", "toe", "hallux", "digit", "diabetes" and "ulcer". Peer reviewed primary research study designs specified as suitable for systematic reviews by the Centre for Reviews and Dissemination were included. Studies were excluded if they used a concurrent secondary procedure or included non-diabetic patients without reporting outcomes separately. Included studies were appraised for quality using the Methodological Index for Non-Randomised Studies tool. Levels of evidence were subsequently assigned to each outcome of interest (healing rate and prevention of re-ulceration). RESULTS From a total search yield of 42 articles, 5 eligible studies (all case series designs) were identified for inclusion. Included studies were of low-to-moderate methodological quality when assessed using the MINORS tool. A total of 250 flexor tenotomy procedures were performed in a total of 163 patients. Included studies generally reported good healing rates (92-100 % within 2 months) post-op follow-up), relatively few recurrences (0-18 % at 22 months median post-op follow-up), and low incidences of infection or new deformity. Transfer ulcers developing on adjacent areas as a result of shifted pressure were reported by several authors. The validity of these results is undermined by methodological limitations inherent to case series designs such as a lack of control groups, non-randomised designs, as well as inconsistent reporting of post-intervention follow-up periods. There was level 4 evidence for the flexor tenotomy procedure in facilitating ulcer healing and preventing re-ulceration. CONCLUSION More definitive research evidence is needed in this area to determine whether or not the flexor tenotomy is a safe and effective treatment option for people with, or at risk of developing diabetic toe ulcers. Whilst the available literature reports that the procedure may be associated with high healing rates, relatively low recurrence rates and low incidences of post-op complications, methodological limitations restrict the value of these findings.
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Affiliation(s)
- Jennifer E Scott
- School of Health and Life Sciences / Institute for Applied Health Research, Glasgow Caledonian University, Cowcaddens Road, Glasgow, G4 0BA UK
| | - Gordon J Hendry
- School of Health and Life Sciences / Institute for Applied Health Research, Glasgow Caledonian University, Cowcaddens Road, Glasgow, G4 0BA UK
| | - John Locke
- School of Health and Life Sciences / Institute for Applied Health Research, Glasgow Caledonian University, Cowcaddens Road, Glasgow, G4 0BA UK
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