Treatment of metatarsalgia based on claw toe deformity through soft tissue release of the metatarsophalangeal joint and resection of the proximal interphalangeal joint: Evaluation based on foot kinematics and plantar pressure distribution.

INTRODUCTION: This study investigated the effect of operative claw toe correction with release of the metatarsophalangeal (MTP) joint, repositioning of the plantar fat pad and resection of the proximal interphalangeal joint on foot kinematics, plantar pressure distribution and Foot Function Index (FFI). METHODS: Prospective experimental study with pretest-posttest design. The plantar pressure, 3D foot kinematics and the FFI of 15 patients with symptomatic claw toes were measured three months before and 12months after surgery. Mean pressure, peak pressure and pressure time integral per sensor and various foot angles were calculated for the pre- and posttest and compared to a control group (N=15). RESULTS: Claw toe patients have increased pressure under the distal part of the metatarsal head and less pressure under the proximal part of the metatarsal heads compared to healthy controls. After surgery, there was a redistribution of pressure, resulting in a significant decrease of pressure under the distal part and an increase under the proximal part of the metatarsal head, providing a more equal plantar pressure distribution. Except for some small areas under the forefoot, heel and toes, there were no significant differences in pressure distribution between the operated feet and controls. Small, but significant differences between the pre- and postoperative condition were found for the lateral arch angle, calcaneus/malleolus supination and tibio-talar flexion. The score on the FFI improved statistically significant. DISCUSSION: These findings imply that the present operative procedure results in a more equal distribution of the plantar pressure under the forefoot and decrease of pain and offers successful treatment of metatarsalgia based on claw toe deformity.

Comparison of Percutaneous Reduction and Pin Fixation in Acute and Chronic Pediatric Mallet Fractures.

BACKGROUND: Although pediatric mallet fractures are more common than adult fractures, no techniques have focused on surgical fixation of pediatric mallet fractures. This study aims to describe the technique and results of percutaneous reduction and fixation in acute and chronic pediatric mallet fractures. METHODS: This is a retrospective review of 51 pediatric mallet fractures treated with percutaneous wire fixation from 2007 to 2014; 38 were acute fractures and 13 were chronic (>4 wk from injury). Surgical technique was identical for all fractures: (1) levering the dorsal fragment into its anatomical bed with a percutaneous towel clip; (2) percutanously transfixing the distal interphalangeal joint in slight hyperextension; (3) placing 2 percutaneous kirschner wires, 1 radial and 1 ulnar, from the dorsal epiphyseal fragment to the volar metaphyseal cortex. Outcomes were defined by the Crawford classification. RESULTS: Average age was 14.6 years (range, 11 to 18 y). Mean time from injury to surgery was 16.2 days in the acute group and 50.8 days in the chronic group. Mean joint surface involvement was 50.8% of the articular base with a mean of 2.0 mm of articular gap (acute fractures 1.9 mm, chronic fractures 2.5 mm, P=0.017). Average preoperative extensor lag was 24.6 degrees. Average operative time was 31 minutes for acute fractures and 40 minutes for chronic fractures. Mean length of follow-up was 78.5 days. At final follow-up, all patients healed with an articular gap of 0.2 mm in the acute group and 0.6 mm in the chronic group (P=0.037) with no nonunions or volar subluxations. All patients but 8 (5 acute, 3 chronic) achieved full extension with an average extensor lag of 1.1 degree for the entire cohort. No patient had >10-degree extensor lag at final follow-up. All patients achieved full active flexion of 90 degrees at final follow-up. In the acute group, the Crawford classification was excellent in 87% (33/38), good in 13% (5/38). In the chronic group, results were excellent in 77% (10/13), good in 23% (3/13) (P>0.05). There were no fair or poor outcomes in either group. A clinical dorsal bump was noted in 18% of patients (22% in the acute group, 15% in the chronic group, P>0.05). There were no infections, wire breakages, nail deformities, or unplanned returns to surgery. CONCLUSIONS: This percutaneous surgical technique to treat pediatric mallet fractures achieves favorable clinical and radiographic results with minimal complications, even in chronic fractures. Results are better than reported for adult mallet fractures. LEVEL OF EVIDENCE: Level II.

The Effect of Percutaneous Flexor Tenotomy on Healing and Prevention of Foot Ulcers in Patients With Claw Deformity of the Toe.

Claw deformity of the foot is frequently seen in patients with diabetes mellitus. Percutaneous flexor tenotomy is a simple surgical procedure for the treatment of foot ulcers on the distal end of the toe caused by this deformity. This procedure can also be performed to prevent ulcers in claw toes that are at risk of ulceration. The aim of this study is to investigate whether percutaneous flexor tenotomy is an effective surgical method for treatment and prevention of toe ulcers in patients with claw deformity. This retrospective study, with a median follow-up of 13.4 (1 to 66.7) months, included all consecutive patients who underwent percutaneous flexor tenotomy in 2 hospitals between July 2012 and April 2017. In total, 101 feet underwent flexor tenotomy: 84 (83.3%) therapeutic and 17 (16.7%) prophylactic. Of the 84 therapeutic procedures, 95.1% healed, with a median healing time of 27 days. In 11 (13.3%) therapeutic procedures, a reulceration was recorded. In the therapeutic group, 4 (4.8%) infections and 1 (1.2%) amputation of the digit occurred. In the 17 prophylactic procedures, local bleeding was recorded in 1 (5.9%). In the prophylactic group, 2 ulcers occurred. In 77 (76.2%) of all procedures, patients had diabetes mellitus. In conclusion, percutaneous flexor tenotomy is an effective, safe, and minimally invasive procedure for the treatment and prevention of toe ulcers in patients with claw deformity.

Percutaneous Kirschner Wire Versus Commercial Implant for Hammertoe Repair: A Cost-Effectiveness Analysis.

Hammertoe deformities are one of the most common foot deformities, affecting up to one third of the general population. Fusion of the joint can be achieved with various devices, with the current focus on percutaneous Kirschner (K)-wire fixation or commercial intramedullary implant devices. The purpose of the present study was to determine whether surgical intervention with percutaneous K-wire fixation versus commercial intramedullary implant is more cost effective for proximal interphalangeal joint arthrodesis in hammertoe surgery. A formal cost-effectiveness analysis using a decision analytic tree model was conducted to investigate the healthcare costs and outcomes associated with either K-wire or commercial intramedullary implant fixation. The outcomes assessed included long-term costs, quality-adjusted life-years (QALYs), and incremental cost per QALY gained. Costs were evaluated from the healthcare system perspective and are expressed in U.S. dollars at a 2017 price base. Our results found that commercial implants were minimally more effective than K-wires but carried significantly higher costs. The total cost for treatment with percutaneous K-wire fixation was $5041 with an effectiveness of 0.82 QALY compared with a commercial implant cost of $6059 with an effectiveness of 0.83 QALY. The incremental cost-effectiveness ratio of commercial implants was $146,667. With an incremental cost-effectiveness ratio of >$50,000, commercial implants failed to justify their proposed benefits to outweigh their cost compared to percutaneous K-wire fixation. In conclusion, percutaneous K-wire fixation would be preferred for arthrodesis of the proximal interphalangeal joint for hammertoes from a healthcare system perspective.

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.

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.

Complications of Lesser Toe Surgery: How To Avoid Them before Surgery and How To Assess and Treat Them When They Have Occurred.

Complications following lesser toe surgery are challenging to manage. The keys to treatment of any of these conditions are, first, to try to avoid them through identification of patient- and surgeon-related variables that contribute to their development and, second, following the occurance of a complication, to understand what can and cannot be corrected with surgical and nonsurgical management. This review provides a comprehensive assessment of current literature, demonstrates best practices and approaches to lesser toe complications, and provides an illustration of clinical examples.

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.

[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.

Percutaneous Kirschner Wire Repair of Failed Digital Arthrodesis Using Pulsed Electromagnetic Field Therapy A Case Report.

A case of a repaired failed toe arthrodesis is presented. A novel and previously unreported approach using a percutaneously placed Kirschner wire coupled with a pulsed electromagnetic field achieved healing of a painful pseudoarthrosis at 54 days. With a percutaneous technique, open debridement of the failed arthrodesis site can be avoided.

Crossover second toe: demographics, etiology, and radiographic assessment.

BACKGROUND: The purpose of this study was to determine the demographics, etiology, and radiographic findings associated with a crossover second toe deformity. METHODS: Patients treated operatively for a crossover second toe deformity between 2001 and 2006 were identified. Charts were reviewed for clinical information, and radiographs were examined for pertinent angular measurements. RESULTS: Of 169 patients in the study, 146 (86%) were women. The mean age at surgery was 59 (range 33 to 87) years. The most common complaints of preoperative pain were at the second (156 patients) and first (35 patients) metatarsophalangeal joints (several patients had more than one area of pain). A positive drawer sign was noted in 112 patients. The mean second and third metatarsophalangeal joint angles were -3 degrees and 6 degrees, respectively. There was a significant association of hallux valgus with first metatarsophalangeal joint arthritis (p < 0.01). The relative length of the second metatarsal averaged 0.2 mm less than the first metatarsal. CONCLUSIONS: Crossover second toe deformity had a peak incidence in women over the age of 50 years. There was an increased incidence of both hallux valgus and first metatarsophalangeal joint degenerative arthritis in the patient cohort. A positive drawer sign was a reliable and consistent physical examination finding. The most reliable radiographic indicator of a second crossover toe was medial angular deviation of the second metatarsophalangeal joint in relationship to the third metatarsophalangeal joint angle, although the angle was not necessarily a negative value. There was no correlation between a crossover second toe deformity and second metatarsal length, medial cortex thickness or shaft thickness, the 1-2 intermetatarsal angle, metatarsus adductus, metatarsus primus elevatus, or pes planus.

Hammertoe Correction With K-Wire Fixation Compared With Percutaneous Correction.

BACKGROUND: Kirschner wire (K-wire) fixation for correction of hammertoe deformity is the gold standard for hammertoe surgery fixation, the current study compares it to percutaneous surgery with 3M Coban dressings. METHODS: All hammertoe corrections performed were retrospectively reviewed. For the K-wire fixation group: resection arthroplasty of the proximal interphalangeal joint was performed and fixed with a K-wire. The percutaneous technique used involved percutaneous diaphyseal osteotomy of the middle and proximal phalanges combined with tendon release. The toes are then wrapped in 3M Coban dressing for 3 weeks. Follow-up duration, preoperative diagnosis, pin duration, concomitant procedures, visual analogue scale (VAS) pain, recurrence rates, and complications were reviewed and analyzed. A total of 352 patients (87 percutaneous/265 open), in whom 675 hammertoes (221 percutaneous/454 open) were corrected. There were 55.9% females, with an average age of 52.8 years, followed for 6 months. The percutaneous group had more diabetics and multiple toes surgery. RESULTS: Complications of the open surgery group included 5.5% pin migrations, 4.5% infections, and 8 (3%) had impaired wound healing. There were 6.2% recurrent deformities and 2.6% toes were revised. Malalignment was noted in 3.3% toes. Vascular compromise occurred in 0.5%, with 0.25% amputated. Complications of the percutaneous surgery group included 18.4% cases of impaired healing and 2.3% infection. Deep tissue dehiscence occurred in 4.5% of open surgery patients. VAS score decreased in both groups with a more pronounced decline in the percutanteous group (2 ± 2.1 vs 0.5 ± 1.6). The per toe infection rate of patients undergoing open hammertoe correction was 5.3% was significantly higher than with the percutaneous correction group, which was 2.2%. CONCLUSIONS: K-wire fixation and percutaneous surgery have similar abnormal healing rates, alignment and patient satisfaction but the latter technique has fewer infections. LEVELS OF EVIDENCE: Level III: Prospective case series with noncontamporenous cohorts.

Elevated plantar pressures in neuropathic diabetic patients with claw/hammer toe deformity.

Elevated plantar foot pressures during gait in diabetic patients with neuropathy have been suggested to result, among other factors, from the distal displacement of sub-metatarsal head (MTH) fat-pad cushions caused by to claw/hammer toe deformity. The purpose of this study was to quantitatively assess these associations. Thirteen neuropathic diabetic subjects with claw/hammer toe deformity, and 13 age- and gender-matched neuropathic diabetic controls without deformity, were examined. Dynamic barefoot plantar pressures were measured with an EMED pressure platform. Peak pressure and force-time integral for each of 11 foot regions were calculated. Degree of toe deformity and the ratio of sub-MTH to sub-phalangeal fat-pad thickness (indicating fat-pad displacement) were measured from sagittal plane magnetic resonance images of the foot. Peak pressures at the MTHs were significantly higher in the patients with toe deformity (mean 626 (SD 260)kPa) when compared with controls (mean 363 (SD 115) kPa, P<0.005). MTH peak pressure was significantly correlated with degree of toe deformity (r=-0.74) and with fat-pad displacement (r=-0.71) (P<0.001). The ratio of force-time integral in the toes and the MTHs (toe-loading index) was significantly lower in the group with deformity. These results show that claw/hammer toe deformity is associated with a distal-to-proximal transfer of load in the forefoot and elevated plantar pressures at the MTHs in neuropathic diabetic patients. Distal displacement of the plantar fat pad is suggested to be the underlying mechanism in this association. These conditions increase the risk for plantar ulceration in these patients.

Reduction of Dorsal Displacement of the Proximal and Middle Phalanges Using a Neutral or Angled Implant for Joint Arthrodesis to Treat Hammertoe Deformity A Finite Element Study.

BACKGROUND: We used finite element analysis to study the mechanical displacements at three planes of the second through fourth hammertoes during the push-off phase of gait using a new neutral or 10° angled memory alloy intramedullary implant (FDA K070598) used for proximal interphalangeal joint arthrodesis. METHODS: After geometric reconstruction of the foot skeleton from computed tomographic images of a 36-year-old man, an intramedullary implant was positioned in the virtual model at the neutral and 10° angled positions at the proximal interphalangeal joints of the second through fourth hammertoes during the push-off phase of gait. The obtained displacement results in three planes were compared with those derived from the nonsurgical foot model using finite element analysis. RESULTS: These results support the successful use of either a neutral or angled implant for proximal interphalangeal joint arthrodesis, with the neutral implant yielding slightly better results. CONCLUSIONS: The neutral implant reduced vertical displacement to a greater extent than did the angled implant. We also highlight the potential risk of iatrogenic curly toe when performing a proximal interphalangeal joint arthrodesis using an angled implant specifically at the fourth toe.

Forefoot structural predictors of plantar pressures during walking in people with diabetes and peripheral neuropathy.

Various foot structures are thought to influence forefoot plantar pressures during walking. High peak plantar pressures (PPP) during walking in people with diabetes mellitus (DM) and peripheral neuropathy (PN) can cause skin breakdown. The question addressed by this study is "What are the primary forefoot structural factors that predict regional PPP during walking in groups of people with and without DM and PN?" Twenty people with DM and PN (mean age 55+/-9 years, 6 female, 14 male, BMI=33+/-8) and 20 people without DM, matched for gender, age, and BMI were tested. Measures of foot structure were taken from three-dimensional images constructed from spiral X-ray computed tomography. Peak plantar pressure data were recorded during walking. Hierarchical multiple regression analysis was used to predict regional PPP at the great toe and five metatarsal heads from selected structural and walking variables. Metatarsal phalangeal joint angle (hammer toe deformity) was the most important variable predicting pressure, accounting for 19-45% of the PPP variance at five of the six locations in the DM group. Soft tissue thickness, hallux valgus, and forefoot arthropathy were the most important predictors of PPP in the control group. Combinations of structural and walking variables accounted for 47-71% of the variance in the DM group and 52-83% of the variance of PPP during walking in the control group. These structural variables, especially hammer toe deformity, should be considered in attempts to develop strategies to reduce excessive forefoot PPP that may contribute to skin breakdown or other injury.

Lesser toe abnormalities.

Lesser toe abnormalities, which can result in significant pain and discomfort, are caused by several intrinsic or extrinsic factors including inflammatory arthritis, trauma, congenital abnormalities, neuromuscular disorders, or poorly fitting shoe wear. Identification of the etiology of the deformity is necessary to determine whether conservative or surgical treatment is warranted and to possibly halt progression of the deformity.

[Lesser toe deformities]. / Hammerzeh tut weh--diese und andere Zehendeformitäten.

Lesser toe deformities often lead to painful calluses and metatarsalgia. Depending on the different underlying etiologies it is mandatory to perform a meticulous clinical assessment including the whole foot and the entire lower limb. Prior to any surgical interventions it is necessary to evaluate the deformity at all three joint levels. The metatarsophalangeal joint acts as a key joint. Any dorsal subluxation or dislocation has to be addressed first. This may include various soft tissue procedures and shortening osteotomies of the metatarsals. After successful realignment contractures of the distal joints have to be corrected. Since function of the lesser toes mainly depends on stability of the distal joints arthrodeses of the proximal and distal interphalangeal joints are superior to any resection arthroplasties.

Hallux claw toe.

Claw hallux is a deformity of the great toe attributed to muscular imbalance. This article describes diagnosis and treatment of this condition. Particular attention is given to surgical techniques such as Jones technique and modified Jones technique.