Toes Deformities in Cavovarus: How to Approach Them.

Sagittal lesser toe deformities (LTD) are the most common in cavus foot. They are mainly the result of muscular imbalance between intrinsic and extrinsic muscles. Surgery is the second-line treatment if medical treatment fails. The aim of the present study was to provide an update on classification and surgical management of LTD in cavus foot including percutaneous procedures with a special focus on sagittal deformities. Joint sparing procedures are preferred for reducible LTD, whereas lesser toe fusions are used for rigid one in association with tendon transfer or percutaneous procedures depending of surgeon's experience and patient's clinical examination.

Lesser-toe deformity.

Lesser-toe deformity is frequent and varied, with severe functional impact. In elderly subjects, it leads to loss of autonomy and increases the risk of falls. The aim of the present study was to provide an update on management, addressing 5 questions. What are the normal anatomy and pathophysiology? These acquired deformities mainly result from imbalance between the intrinsic and extrinsic muscles of the foot or from capsule-ligament stabilizer failure. How to analyze the deformity? It is important to identify the cause, site, reducibility and metatarsophalangeal joint stability. What are the main deformities and how should they be classified? Classifications used to be based on confusing terminology as the deformities were poorly defined. The French Foot Surgery Association (AFCP) therefore validated a classification with standardized, exhaustive and reproducible morphologic descriptions. What treatments are there? Treatment needs to take account of the cause. Footwear adaptation, physiotherapy and podologic measures are in first line, with surgery in second line. Surgery concerns soft tissues (tendon lengthening, tendon transfer, arthrolysis, plantar plate repair), bone (metatarsal and phalangeal osteotomy) and joints (replacement and fusion), with percutaneous and open approaches. What are the treatment strategies? Surgery is performed sequentially, from proximal to distal, if necessary. Options are set out in the decision-trees included in this article. LEVEL OF EVIDENCE: V, expert opinion.

Podoscopic classification of second toe deformities.

BACKGROUND: The AFCP (French Association of Foot Surgery) classification was recently introduced as a reliable and quick visual method for the assessment of sagittal plane deformities of the second toe. The aim of this study was four-fold: (1) to describe a new toe-ground area score (TAS) as an additional dynamic tool of such classification, (2) to verify whether all second toe deformities could be classified, (3) to assess the TAS intra- and inter-observer reliability and (4) to evaluate the TAS learning curve. METHODS: In this retrospective study 52 s toes were evaluated using a podoscope. Ten foot and ankle surgeons assessed independently standardised videos of each case acquired in a blinded fashion. Assessment was repeated three times, 15 days apart. Intra- (Intraclass Correlation Coefficient or ICC) and inter-observer reliability (Fleiss' Kappa coefficient) were calculated. Mean time to assess a deformity was also recorded. RESULTS: All the 522 observations (52 feet assessed by 10 surgeons) were successfully rated using the TAS. Intra- and inter-observer reliability were substantial for the first round (ICC: 0.79; Kappa: 0.76) and excellent for the second (ICC: 0.88; Kappa: 0.8) and third round (ICC: 0.84; Kappa: 0.81). Mean assessment time ± standard deviation was 22 ± 11 s per case for the last two rounds. CONCLUSIONS: The TAS has been proven reliable and quick in the assessment of second toe deformities. When combined with a static segmentary classification of the toe (such as the AFCP classification) it might provide further dynamic informations about the ability of the toe to engage the ground. LEVEL OF EVIDENCE: Level IV, retrospective cohort study.

Intra- and inter-observer reliability of the AFCP classification for sagittal plane deformities of the second toe.

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.

Tibiotalocalcaneal arthrodesis using a straight intramedullary nail.

BACKGROUND: Tibiotalocalcaneal (TTC) arthrodesis is a proven solution for severe hindfoot arthropathy that reestablishes stability for plantigrade gait and alleviates pain, while correcting deformity. Intramedullary nailing is an effective option for fixation. The aim of this study was to determine clinical outcome, analyze the fusion rate, and determine final hindfoot alignment in a consecutive series of patients using a single-design straight intramedullary nail. METHODS: This study evaluated 63 patients treated between 2006 and 2010 with at least 36 months of follow-up. Ten patients were excluded because of study inclusion criteria, and 4 were lost to follow-up, leaving 49 patients available for review. The average follow-up was 70.7 ± 15.1 months. RESULTS: The American Orthopaedic Foot and Ankle Society score improved from 29.7 ± 15.1 before arthrodesis to 65.8 ± 14.6 after (P < .001) with 83.7% (41/49) of patients stating they were satisfied or very satisfied with the outcome. The hindfoot angle improved from -3 ± 15 degrees (varus) before the arthrodesis to 3.5 ± 4 degrees (valgus) after; the tibiotalar angle averaged 103 ± 4.2 degrees after the arthrodesis. Fusion occurred in both joints in 86% (42/49) of patients and in 93% (91/98) of all joints. The average time to fusion was 4.5 ± 2 months. Current smokers had a significantly (P = .03) higher risk of complications. Use of an allograft, with or without bone morphogenetic protein 2, led to comparable results even in the presence of a large bone defect. CONCLUSION: These results are comparable to previously published studies using intramedullary nailing to achieve tibiotalocalcaneal arthrodesis. The complication concerns typically associated with straight nails were not found. We recommend using a retrograde intramedullary nail for the fixation of TTC arthrodesis and adding an allograft in cases of significant bone loss. LEVEL OF EVIDENCE: Level IV, consecutive case series.