2 nd MTP Instability: What Works? Daniel J. Cuttica, DO AOAO 2011 Annual Meeting Chicago, IL

Transcription

1 2 nd MTP Instability: What Works? Daniel J. Cuttica, DO AOAO 2011 Annual Meeting Chicago, IL

2 Overview Pathoanatomy Etiology Patient presentation Imaging Treatment

3 Anatomy Extrinsic: EDL, EDB, FDL, FDB Intrinsic: Interossei, lumbricals Passive restraints: Plantar plate, collaterals, capsule

4 Pathoanatomy Longer 2 nd ray Limited motion of 2 nd TMT joint Greater stresses at 2 nd MTP joint Reactive synovitis attenuation of planar plate/collateral MTP instability Plantar plate: dorsal subluxation Collaterals: medial/lateral deviation

5 Etiology Trauma Repetitive microtrauma Systemic arthritides Hallux valgus Long 2 nd ray Steroid injection

6 Presentation Synovitis of 2 nd MTP Local swelling of joint/toe Tenderness Deformity Intractable plantar keratosis or plantar callus Hammertoe

7 Drawer sign Toe grasped between thumb and forefinger Toe DF to 25 Dorsal force to attempt to subluxate toe Instability: Laxity and pain

8 2 nd MTP Instability vs Neuroma 20 percent of cases in which IDN excised also demonstrated MTP instability Coughlin and Schenck FAI 2002 IDN: Pain in webspace Neuritic pain and numbness MTP instability: Pain localized to MTP joint

9 Grading system (Coughlin) Grade 0 (No instability) Joint pain/thickening/swelling Grade 1 (Mild instability) Positive drawer sign, but no malalignment or deformity Grade 2 (Moderate instability) Positive drawer sign Medial, lateral, dorsal, or dorsomedial deformity Grade 3 (Severe instability/dislocation) Positive drawer sign Overlapping of hallux by 2 nd toe Grade 4 (Severe instability/dislocation) Fixed deformity

10 Imaging Standing radiographs MTP joint widening (synovitis) MTP joint narrowing (subluxation/dislocation/arthritis) Deviation from midline Dorsal subluxation/dislocation on lateral x-ray Bone scan/mri rarely necessary

11 Nonoperative Treatment Shoewear modifications High/wide toe box Avoid high heels/flexible shoes Taping Orthotics MT pad prox to MT head NSAIDs Steroid injections Can lead to capsular attenuation Temporary relief

12 Preop Planning Degree of instability Mild/Moderate/Severe/Dislocation Hallux valgus Hammertoe Flexible vs rigid Vascular and neurologic exam

13 Mild/Moderate Subluxation Soft tissue release Capsular reefing EDB transfer Flexor tendon transfer

14 Soft tissue release Dorsal incision over MTP Release dorsal capsule and collaterals Adhesions b/t MT head and plantar capsule Extensor tendon Z-lengthening Test for stability Dorsiflex/plantarflex ankle toe should remain reduced

15 Capsular reefing Release of contracted capsular structures Reefing of elongated capsule If paucity of tissue, can use suture anchor Allows 5-10 axial plane realignment

16 EDB transfer Soft tissue release EDB tendon released 4 cm prox to MTP joint Distal EDB passed beneath transverse IM ligament Reattached to prox stump with toe correctly aligned K wire used to hold toe reduced prior to reattachment

17 Flexor to extensor transfer Plantar incision at PIP joint FDL identified Midline raphe FDL tagged, released and split longitudinally FDL delivered dorsally and sutured to extensor expansion in 20 PF

18 Results Coughlin Combination of soft tissue realignment procedures 11 pt (15 toes) 93% good/excellent results Younger, athletically active pt 9 pt (11 toes) 71% good/excellent results

19 Results Dhukaram et al (JBJS 2002) 69 pt (157 toes) Soft tissue release with hammertoe correction 2 recurrent instability Weil osteotomy 14% moderate/severe pain

20 Results Hadad et al (FAI 1999) 19 EDB transfers Successful realignment in 14/19 pts (74%) Stiffness and continued pain common complaint

21 Flexor-to-extensor transfer Inconsistent levels of pt satisfaction: 51-89% Myerson et al (Foot Ankle Int 2005) 64 feet (59 pts) 78% stability; 34% dissatisfied 22 (37%) with residual DF 16 (27%) persistent medial deviation Complications: Stiffness Swelling Transient numbness DIP joint hyperext

22 Severe Subluxation/Dislocation Soft tissue release Bony procedures/joint decompression Realigns toe Less tension on neurovascular strucures

23 Weil osteotomy Most widely used Distal oblique osteotomy in MT metaphyseal region 2-6 mm shortening Allows med/lat translation to improve axial alignment Large area of bone contact for stable fixation and union

24 Weil osteotomy Saw blade penetrates MT head 2mm inferior to dorsal surface Parallel to plantar surface of foot Distal fragment translated proximally Stabilized with dorsal to plantar screw

25 Weil osteotomy Khalafi et al (FAI 2005) Assessed plantar pressure changes assoc with Weil osteotomy of 2 nd MT Pressure decrease: 36% foot in neutral 65% at heel rise

26 Results Hofstatter et al (JBJS Br 2005) Prospective study of short and long-term results of Weil osteotomy 25 feet Good to excellent results in 88% cases Reduced pain Diminished plantar callus formation Increased walking capacity Recurrence: 12% cases

27 Results Multiple retrospective studies Good to excellent results with pain relief and resolution of plantar callus formation in % of patients Advantages: Stable fixation High union rates Controlled shortening Low incidence of complications Disadvantage: Difficulty obtaining correct amount of shortening Insufficient shortening: persistent pain Excessive shortening: transfer lesion

28 Results Floating toe Toe does not touch ground with WB 15-30% incidence Intrinsic muscles dorsal to center of rotation from excessive plantar translation Mimimize incidence: Extensor tendon lengthening Osteotomy parallel to plantar surface of foot Dorsal wedge resecton Stiffness Transfer metatarsalgia Too long screw plantar pain

29 Weil modifications Prevent excessive shortening and plantar translation of MT head Melamed et al Dorsal oblique bone wedge resection Removal of 1mm wedge 0.5mm shortening and 0.6mm elevation

30 Weil modifications Triple Cut Osteotomy (Maceira et al) 1 st cut: Dorsal and prox to MT head/neck jxn in oblique & plantar direction 2 nd cut: Prox fragment perpendic to floor Based on amt of desired shortening 3 rd cut: Parallel to 1 st oblique cut Fixation: 2.0mm screw

31 Triple cut osteotomy Advantages: Maintains anatomy of MT head No plantar spike Decreased floating toe Preserves relationship of intrinsics Decreased stiffness Disadvantages: Fixation stability d/t obliquity of cut Fx of proximal fragment Nonunion.malunion

32 Midshaft MT segmental osteotomy Equalizes lengths of lesser MTs MT exposed at level of resection 2 parallel cuts perpendicular to MT shaft 5mm resected 4-hole one-quarter tubular plate w/ 2.7mm screws

33 Results Galuch et al (FAI 2007) 99.2% union rate (125/126 osteotomies) Predictable shortening Less stiffness at MTP Short-term results No outcome assessment Potential for HWR complications Location theoretically assoc with increased risk of delayed union/nonunion

34 Plantar plate repair Address pathology of plantar plate Occurs at distal attachment of base of prox phalanx Dorsal vs plantar approach Cooper et al (Foot Ankle Int 2011) Dorsal exposure of 2 nd MTP in 8 specimens Weil osteotomy allowed greatest exposure of plantar plate

35 Plantar plate repair Dorsal exposure/soft tissue release/weil osteotomy Plantar plate advancement and securing it to prox phalanx thru drill holes Gregg et al (Foot Ankle Surg 2007) 23 pts (35 toes) Avg AOFAS score: floating toes

36 Plantar plate repair Weil et al (Foot Ankle Spec 2011) 11/13 improved function 10/13 satisfied/very satisfied No recurrence/floating toes 3/13 painful 2 nd MTP stiffness

37 Post op vascular insufficiency Increased tension or kinking of vessels following correction Loosen dressing Lower leg Nitroglycerin ointment Remove K-wire

38 Salvage procedures Failed prior procedure/recurrence Severe deformities MTP joint DJD

39 Salvage Procedures DuVries MTP arthroplasty Dorsoplantar osteotomy Removes distal 3-4mm MT +/- EDB interposition MT head resection Prox phalangectomy with syndactylization Amputation

40 References: Coughlin MJ, Schenck RC Jr, Shurnas PS, et al. Concurrent interdigital neuroma and MTP joint instability. Long-term results of treatment. Foot Ankle Int. 2002; 23: Fortin PT, Myerson MS. Second metatarsophalangeal joint instability. Foot Ankle Int. 1995; 16: Hofstaetter SG, Hoefstaetter JG, Petroutsas JA, et al. The Weil osteotomy: a sevenyear follow-up. JBJS-Br. 2005; 87: Weil L Jr, Sung W, Weill LS Sr, et al. Anatomic plantar plate repair using the Weil metatarsal osteotomy approach. Foot Ankle Specialist. 2011; 4: Cooper MT, Coughlin MJ. Sequential dissection for exposure of the second metatarsophalangeal joint. Foot Ankle Int. 2011; 32: Gregg J, Silberstein M, Clark C, Schneider T. Plantar plate repair and Weil osteotomy for metatarsophalangeal joint instability. Foot Ankle Surg. 2007; 13: Espinosa N, Brodsky JW, Maceira E. Metatarsalgia. J Am Acad Orthop Surg. 2010; 18: Myerson MS, Jung HG. The role of toe flexor-to-extensor transfer in correcting metatarsophalangeal joint istability of the second toe. Foot Ankle Int. 2005; 26:

41 References Thompson FM, Deland JT. Flexor tendon transfer for metatarsophalangeal instability of the second toe. Foot Ankle Int. 1993; 14: Espinosa N, Maceira E, Myerson MS. Current concept review: metatarsalgia. Foot Ankle Int. 2008; 29: Melamed EA, Schon LC, Myerson MS, Parks BG. Two modifications of the Weil osteotomy: analysis of sawbone models. Foot Ankle Int. 2002; 23: Khalafi A, Landsman AS, Lautenschlager EP, et al. Plantar forefoot pressure changes after second metatarsal neck osteotomy. Foot Ankle Int. 2005; 26: Galluch DB, Bohay DR, Anderson JG. Midshaft metatarsal osteotomy with open reduction and internal fixation. Shirzad K, Kiesau CD, DeOrio JK, Parekh SG. Lesser toe deformities. J Am Acad Orthop Surg. 2011; 19: Hadad SL, Sabbagh RC, Resch S et al. Results of flexor-to extensor and extensor brevis tendon transfer for correction of the crossover second toe deformity. Foot Ankle Int. 1999; 20: Coughlin MJ. Crossover toe deformity. Foot Ankle. 1987; 8:29-39.

42 References Coughlin MJ. Second metatarsophalangeal joint instability in the athlete. Foot Ankle. 1993; 14: Dhukaram V, Hossain S, Sampath J, et al. Correction of hammertoe with an extended release of the metatarsophalangeal joint. J Bone Joint Surg Br. 2002; 84: