Claw Toe Deformity After Revision Hip Arthroscopy with Concomitant Periacetabular Osteotomy: A Case Report.

CASE: A 22-year-old woman underwent revision right hip arthroscopy (HA) with concomitant periacetabular osteotomy (PAO). The total procedure time was 5.5 hours. After completion of the 3 hour HA portion, the traction boots were loosened. Eleven weeks postoperatively, she developed a left claw toe deformity. After failed conservative management, she underwent lengthening of the left flexor hallucis longus and flexor digitorum longus tendons. CONCLUSION: This is a case of a claw toe deformity after revision right HA with concomitant PAO. The possibility of this complication should be considered in cases with prolonged intraoperative times because of the use of traction boots.

Hallux and Lesser Digits Deformities Associated with Cavus Foot.

It is important to identify the level of the deformity or deformities. It is important to get the limb as close to anatomic alignment as possible. Many levels and multiple procedures may be involved with this reconstruction.

Effectiveness of the Cobb-Stainsby excision arthroplasty.

BACKGROUND: Dislocated metatarsophalangeal joints from clawed or hammer toes can be a disabling consequence of several conditions. The Cobb-Stainsby forefoot arthroplasty combines partial phalangectomy (Stainsby) with extensor tendon transfer to the metatarsal head (Cobb). We present a retrospective, three surgeon case series of 215 toes in 126 patients. METHODS: Early results and complications were gathered from the medical charts of 126 patients who met the inclusion criteria. Seventy-five patients were contactable by phone with a follow up range of 12-82 months (median follow up 45 months). Primary outcome measures were improvement of pain and function, reduction in plantar callosities and cosmetic improvement of the deformity. RESULTS: Pre-operatively all patients presented with pain and shoe wear problems. Post-operatively seventy-two patients (96%) were satisfied, 72 (96%) reported pain relief, 55 (73%) were happy with toe control, 61 (81%) were pleased with cosmesis and 56 (75%) reported unlimited daily activities. Superficial wound infections were observed in 13 of the 126 patients (10%) and two in 75 patients (2%) developed recurrent clawing. CONCLUSION: Our case series demonstrates improved outcomes over alternatives such as the Weil's osteotomy.

Jones Tendon Transfer.

Hallux malleus is a deformity of the great toe. There is a dorsiflexion contracture at the metatarsophalangeal joint and plantar flexion of the interphalangeal joint. The deformity is commonly attributed to muscular imbalances of the various structures acting on the great toe. Jones tendon transfer is a procedure used to remove the deforming force to the clawed hallux. It is most often performed in conjunction with a hallux interphalangeal joint fusion. Typically there is a neurologic component causing a deformity to the entire foot, necessitating adjunct procedures. The Jones tendon transfer has shown to have reproducible results.

Claw Toe Deformity of the Foot due to Foreign Body Granuloma.

UNLABELLED: We present a case of dynamic claw deformity of the right third toe due to a foreign body granuloma adhering to the flexor digitorum longus (FDL) tendon at the level of the body of the metacarpal bone. The deformity was completely corrected after removal of the granuloma and lengthening of the FDL tendon. A 25-year-old woman presented with pain and claw deformity of the right third toe, which corrected with ankle plantar flexion. Ultrasound and magnetic resonance imaging suggested the presence of foreign body granuloma of the right FDL tendon at the level of body of third metacarpal bone. On removal of the granuloma and Z plasty of the FDL tendon, there was complete correction of the claw. In the reported literature, claw deformity is seen with compartment syndrome or ankle fractures due to fixed length phenomenon or checkrein deformity of the flexor tendons usually at the level of medial part of the ankle. Here, we present a case of checkrein claw deformity of the FDL tendon due to a foreign body granuloma. LEVELS OF EVIDENCE: Therapeutic, Level IV: Case study.

Flexor digitorum brevis tendon transfer to the flexor digitorum longus tendon according to Valtin in posttraumatic flexible claw toe deformity due to extrinsic toe flexor shortening.

Claw toe deformity after posterior leg compartment syndrome is rare but incapacitating. When the mechanism is flexor digitorum longus (FDL) shortening due to ischemic contracture of the muscle after posterior leg syndrome, a good treatment option is the Valtin procedure in which the flexor digitorum brevis (FDB) is transferred to the FDL after FDL tenotomy. The Valtin procedure reduces the deformity by lengthening and reactivating the FDL. Here, we report the outcomes of FDB to FDL transfer according to Valtin in 10 patients with posttraumatic claw toe deformity treated a mean of 34 months after the injury. Toe flexion was restored in all 10 patients, with no claw toe deformity even during dorsiflexion of the ankle.

Adhesion of flexor hallucis longus at the site of a tibial-shaft fracture--a cause of a checkrein deformity.

Post-traumatic adhesion of toe flexors at the tibial fracture site resulted in checkrein deformity is rare and only a few case reports or case series were reported in the English literature. Major differential diagnosis includes deep compartment syndrome or adhesion of the muscle due to various causes. We are not able to conclude what is the best treatment option. Open exploration and adhesiolysis at the adhesion site together with tendon lengthening at the distal tibial level is a feasible surgical option with satisfactory result.

A case of check-rein deformities of the great and lesser toes treated through exploration at the midfoot.

We present the case of a twenty-two year old man who presented to the orthopaedic clinic complaining of clawing of his great toe. Further examination revealed clawing of the lesser toes and surgical scarring to the fibula and tibia. A history of previous operative fixation for lower limb trauma was described. Exploration of the flexor hallucis longus (FHL) and flexor digitorum longus (FDL) tendons was performed at the level of the midfoot. A full correction was achieved after release of the inter-tendinous connection between FHL and FDL tendons and z-plasty of the FHL tendon. This case highlights another possible complication of tibial fracture which should be actively looked for in patients with this injury. We describe and illustrate the ease of surgical correction through an operative field free of scar tissue which has the ability to possibly prevent unnecessary tendon z-plasty. We suggest that exploration at the midfoot should be the primary surgical intervention in similar cases of check-rein deformity.

Surgical Treatment Guidelines for Digital Deformity Associated With Intrinsic Muscle Spasticity (Intrinsic Plus Foot) in Adults With Cerebral Palsy.

Intrinsic plus foot deformity has primarily been associated with cerebral palsy and involves spastic contracture of the intrinsic musculature with resultant toe deformities. Digital deformity is caused by a dynamic imbalance between the intrinsic muscles in the foot and extrinsic muscles in the lower leg. Spastic contracture of the toes frequently involves curling under of the lesser digits or contracture of the hallux into valgus or plantarflexion deformity. Patients often present with associated pressure ulcers, deformed toenails, shoe or brace fitting challenges, and pain with ambulation or transfers. Four different patterns of intrinsic plus foot deformity have been observed by the authors that likely relate to the different patterns of muscle involvement. Case examples are provided of the 4 patterns of intrinsic plus foot deformity observed, including global intrinsic plus lesser toe deformity, isolated intrinsic plus lesser toe deformity, intrinsic plus hallux valgus deformity, and intrinsic plus hallux flexus deformity. These case examples are presented to demonstrate each type of deformity and our approach for surgical management according to the contracture pattern. The surgical approach has typically involved tenotomy, capsulotomy, or isolated joint fusion. The main goals of surgical treatment are to relieve pain and reduce pressure points through digital realignment in an effort to decrease the risk of pressure sores and allow more effective bracing to ultimately improve the patient's mobility.

Surgical correction of checkrein deformity after malunited distal tibia fracture: a case report.

Checkrein deformities are rare and involve entrapment or tethering of the flexor hallucis longus and, occasionally, flexor digitorum longus tendons. The deformity has typically been secondary to traumatic fractures of the talus, calcaneus, or deep posterior compartment syndrome resulting from fractures of the tibia and fibula and most fractures of the ankle. These result in flexion contractures at the interphalangeal joint of the hallux. Because of the rarity of this deformity, no single surgical technique has been defined as the standard. Previous interventions have included release of adhesions with or without Z-plasty lengthening of the involved tendons. The present study reports a case of checkrein deformity secondary to a malunited distal tibia fracture, with flexion deformities to digits 1 through 3. The patient underwent successful surgical correction with flexor tenotomies to the affected digits with interphalangeal arthrodesis to the hallux.

Temporary Kirschner wire transfixation versus strapping dressing after second MTP joint realignment surgery: a comparative study with ten-year follow-up.

BACKGROUND: Instability of the second metatarsophalageal (MTP) joint is a common disorder of the forefoot and can be addressed operatively. The objective of this study was to compare a temporary K-wire fixation (tKW) to a postoperative strapping dressing (SD) after realignment surgery of second MTP instability in combination with correction of claw toe deformity. METHODS: Fifty-four consecutive patients with metatarsal index plus or neutral and a collective total of 62 operative interventions were examined at 10 years postoperatively. The operative intervention included dorsal capsulotomy, incision of the extensor hood, and lengthening of the extensor tendon. All operations were carried out at a single institution by orthopedic surgeons experienced in foot surgery. One team preferred fixation with tKW, whereas the other team used only noninvasive SD for postoperative management. The assessment included the American Orthopaedic Foot & Ankle Society (AOFAS) metatarsophalangeal-interphalangeal score as well as the visual analogue scale (VAS) for pain. Kaplan Meier analysis with recurrence of subluxation as the end point was performed, and plain radiographs of the forefoot were investigated. RESULTS: Survival without recurrence of second MTP subluxation was significantly higher in the tKW group (93%) compared with the SD group (88%) (P < .001). There was no statistical significant difference in pre- to postoperative AOFAS and VAS pain between the 2 groups. CONCLUSION: Temporary K-wire fixation had a significantly lower recurrence rate of second MTP subluxation compared with postoperative SD for postoperative alignment management in second MTP instability. LEVEL OF EVIDENCE: Level III, therapeutic study.

Sequelae of underdiagnosed foot compartment syndrome after calcaneal fractures.

The calcaneus is the most frequently fractured tarsal bone. Compartment syndrome (CS) complicates fractures and other injuries and is most commonly described in association with the lower leg. The long-term sequelae of CS of the foot can include toe clawing, permanent loss of function, persistent pain, muscle atrophy, contracture, painful warts, weakness, and sensory disturbances. The incidence and clinical significance of untreated CS after calcaneal fractures were questioned. All compliant patients treated by us for a calcaneus fracture underwent a physical examination and medical interview: 47 (49 fractures) were included in the final cohort (36 males, 11 females, mean age 49 ± 14.5 years, mean follow-up 23 ± 16 months). Missed CS sequelae were diagnosed by the presence of claw toes and plantar sensory deficits. The functional outcome and pain at rest and during activity were scored. Five patients (10%) had missed CS, and their functional score was significantly lower than for those without CS (52 ± 21.5 versus 77.4 ± 22 for no CS, p < .05). All missed CS cases were diagnosed in patients with a Sanders type 3 or 4 fracture. Intra-articular fracture was a significant factor associated with developing CS sequelae (p = .045). Untreated CS can cause muscle and nerve injury and contribute to a poor functional outcome. Because CS is more likely to develop after highly comminuted intra-articular fractures, these patients warrant close monitoring for CS development. Early detection and treatment might result in fewer late disabling sequelae of this injury.

Mallet toe deformity.

Mallet toe is one of the most common deformities encountered by orthopedic surgeons. Care needs to be taken to ascertain whether it is a primary condition or secondary to a systemic disease, especially if multiple deformities are present. There are numerous operative strategies available, but each has its specific indications. If the indications are followed, highly successful outcomes may be achieved.

Lesser toe deformities.

Lesser toe deformities are caused by alterations in normal anatomy that create an imbalance between the intrinsic and extrinsic muscles. Causes include improper shoe wear, trauma, genetics, inflammatory arthritis, and neuromuscular and metabolic diseases. Typical deformities include mallet toe, hammer toe, claw toe, curly toe, and crossover toe. Abnormalities associated with the metatarsophalangeal (MTP) joints include hallux valgus of the first MTP joint and instability of the lesser MTP joints, especially the second toe. Midfoot and hindfoot deformities (eg, cavus foot, varus hindfoot, valgus hindfoot with forefoot pronation) may be present, as well. Nonsurgical management focuses on relieving pressure and correcting deformity with various appliances. Surgical management is reserved for patients who fail nonsurgical treatment. Options include soft-tissue correction (eg, tendon transfer) as well as bony procedures (eg, joint resection, fusion, metatarsal shortening), or a combination of techniques.

Outcomes after the Stainsby procedure in the lesser toes: an alternative procedure for the correction of rigid claw toe deformity.

Clawing of the digits is a deformity seen both in patients with and without rheumatoid arthritis, resulting in pain and deformity in the forefoot. After failure of conservative treatment, the Stainsby procedure is one surgical option for severe clawing and metatarsalgia in both rheumatoid and nonrheumatoid feet. Results from the originating authors (G.D. Stainsby and P.J. Briggs) are consistent and reliable; however, there is little material outside of the originating center. This article reviews our experience in the Western Sussex Hospitals NHS Trust. Sixteen consecutive patients who underwent Stainsby procedure between 2006 and 2009 were reviewed. All operations were performed by a single consultant surgeon, the senior author (S.P.). All patients were scored using the Manchester Oxford Foot and Ankle score preoperatively and postoperatively. Minimum follow-up was 6 months, with a mean follow-up of 14 months. Significant improvements in all scores were seen postoperatively. Walking scores dropped from a mean of 22 preoperatively to 12.7 postoperatively (p = 0.007). Pain scores dropped from a mean of 13.3 to 7.1 (p = 0.001). Social scores dropped from a mean 11 to 6 (p = 0.001). Overall patient satisfaction was high. The Stainsby procedure has been shown to improve function and reduce pain in patients from its originating center in both rheumatoid and nonrheumatoid feet. This study demonstrates this simple technique is reproducible and effective in reducing morbidity.

[Recurrent hammer and clawed toes after surgical correction]. / Rezidive nach Korrektur von Hammer- und Krallenzehen.

Symptomatic lesser toe deformities should be corrected if conservative therapy is exhausted or no longer seems appropriate. Prevention of recurrence starts with the correct indication for the appropriate surgical procedure. The occasional difficult question of the cause of the deformity is crucial in this context. A correct surgical technique and appropriate after-care reduces the risk of recurrence. Due to tensed bony and soft-tissue conditions, revision surgery of the forefoot is challenging. If a revision becomes necessary, the cause of recurrence must be re-examined. This paper explains the appropriate indications and surgical techniques for correction of lesser toe deformities. Subsequently, specific postoperative complications and their management are discussed in detail.

[Resection of the proximal phalanx in hammertoe]. / Reseksjon i proksimale falang ved hammertå.

BACKGROUND: Hammertoe is one of several toe deformities caused by an imbalance between tendons which flex and extend the toes. The condition is most common among women and may be caused by systemic disease, but is most often idiopathic. The standard method of operation is resection of the distal part of the proximal phalanx. We here report an evaluation of our results after operation of hammertoe at a Norwegian hospital. MATERIAL AND METHODS: After reviewing medical records for patients operated for hammertoe (at St. Olav Hospital in a 6-year-period [1999-2004]), we requested the patients to assess the intervention in a mailed questionnaire. Those who still had complaints were asked to come for a clinical check-up. RESULTS: 141 patients were operated for hammertoe in the period; 131 completed the questionnaire. The mean follow-up time was 5 years (range 3-8). 86% of those operated were women and the mean age at the time of operation was 65 years. 25% of the operated patients described that they had been dissatisfied with the results of the primary operation. 41% of those who had been dissatisfied had hyperextension in the metatarsophalangeal (MTP)-joint in addition to flexion in the middle joint. INTERPRETATION: A dissatisfaction rate of 25% is too high. An additional diagnosis of hyperextension of the MTP-joint requires MTP soft tissue release, which differs from the standard operation of hammertoe. We suggest that a better preoperative differentiation between the lesser toe deformities can increase satisfaction with the treatment.

Surgical correction of claw toe deformity following harvesting of fibula flaps.

Complications after the harvesting of vascularized fibula grafts are rare. Here we present our results on patients who developed claw deformity of the great and lesser toes. We discuss the etiology of claw toe deformity and the surgical correction of this condition. Seven patients developed claw toe deformity in the donor side foot after the harvesting of a vascularized fibula graft. They comprised 5 males and 2 females with an average age of 29 years (range: 6-59 years). The affected toes in 6 patients were 1 and 2, or 1, 2, and 3. All toes were affected in the remaining patient. Four patients underwent Z-lengthening of the flexor hallucis longus at the medial malleolus of the ankle, while 3 underwent cutting of the tendons. The average time between harvesting a fibula graft and development of claw toe deformity was 13 months (range: 2.5-42 months), and the average follow-up time was 30 months (range: 10-47 months). Claw deformity of affected toes was successfully corrected in all patients by release of the flexor hallucis longus. Full extension of the affected toes was achieved by the time of final follow-up. Flexion of the interphalangeal joint was preserved in all patients except one who underwent cutting of the tendon beneath the metatarsophalangeal joint. Lengthening or cutting of the flexor hallucis longus tendon at the medial malleolus successfully corrects claw toe deformity following the harvesting of vascularized fibula grafts. Even after cutting the tendon, flexion of the great toe is possible by interconnection with the flexor digitorum longus tendon.