Annual Surgical Conference 2018 Digital Surgery Complications Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018
None Disclosures
Presentation Outline Differentials Neuroma Plantar plate injury Metatarsalgia Hammertoe Influencing factors Anatomy Hammertoe Rigidity Plane(s) of deformity Complications
Presentation Outline Differentials Neuroma Plantar plate injury Metatarsalgia Hammertoe Influencing factors Anatomy Hammertoe Rigidity Plane(s) of deformity Complications Treatment options Arthrodesis Tendon transfers Flexor tenotomy Girdlestone-Taylor Variations EDB transfer Hibbs What have I learned? Arthroplasty needs to be retired
Plantar Plate Subjective Walking on pebble Wart under foot Pain Under MPJ MPJ effusion Biomechanical Hammertoe Hallux abductovalgus Elongated 2 nd metatarsal 1 Equinus Iatrogenic Steroid 2 1. Klein, et al, Foot Ankle Spec 6:2, 2013. 2. Reis, et al., J Bone Joint Surg 71B:5, 1989.
Differential Diagnoses Misdiagnosis Capsulitis / Synovitis Freiberg s disease Arthritides Stress fracture Neuroma 1 Single 97/279 3 rd interspace 74.2% 2 nd MPJ plantar exposure Multiple 182/279 2 nd interspace 98.9% 3 rd interspace 100.0% 2 nd IMS neuroma 1. Valero, et al., J Foot Ankle Surg 54:3, 2015.
The Plantar Plate Plantar plate function Stabilize MPJ with lumbricales and FDL Resists DF tensile forces Offers gliding surface for flexor tendons Weakest at base of phalanx 1 Assists Windlass mechanism Lachman test DF toe at 25 Translate dorsally / plantarly 1. Jolly, in Master Techniques in Podiatric Surgery: The Foot and Ankle, ed. Chang, Lippincott, Williams and Wilkins, Philadelphia, 2005.
Staging MPJ Instability Stage 1 Subtle edema with pain to plantar MPJ Most (70-90%) alleviate in several days Stage 2 Moderate edema Radiographic deviation of digit Loss of toe purchase Poor response to conservative treatment Stage 3 Moderate edema Frank subluxation/dislocation Often seen with HAV deformity Rarely responds to conservative treatment Yu and Judge, in Reconstructive Surgery of Foot and Leg, editors Camasta, et al., Podiatry Institute Publishing, pp109-13, 1995.
Staging MPJ Instability Grade 0- No instability No joint pain, thickening, or swelling Prodromal phase but no deformity Grade 1- Mild instability Synovitis and mild deviation Positive drawer sign without significant deformity Grade 2- Moderate instability Dorsomedial deviation/subluxation Positive drawer sign with deformity Grade 3- Dislocated MPJ Positive drawer sign with cross-over deformity Grade 4- Rigid dislocated MPJ Haddad, et al., Foot Ankle Int 20:12, 1999.
Imaging Radiographs Ultrasound Dynamic Arthrogram MRI
Imaging Radiographs Ultrasound Dynamic Arthrogram MRI Base of phalanx MTH
Imaging Radiographs Ultrasound Dynamic Arthrogram MRI Base of phalanx Normal plantar plate MTH
Imaging Radiographs Ultrasound Dynamic Arthrogram MRI
Imaging Radiographs Ultrasound Dynamic Arthrogram MRI
Imaging Radiographs Ultrasound Dynamic Arthrogram MRI Yao, et al., Am J Roentgenol 163:3, 1994.
Imaging Radiographs Ultrasound Dynamic Arthrogram MRI
Hammertoe Complications Reproducibility Predictable results Arthrodesis Retire the arthroplasty Typical complications Incision contracture Prolonged swelling Floating toe Poor purchase Deviated toe if performing arthroplasty Issues with K-wires
Hammertoe Complications Reproducibility Predictable results Arthrodesis Retire the arthroplasty Typical complications Incision contracture Prolonged swelling Floating toe Poor purchase Deviated toe if performing arthroplasty Issues with K-wires Proposed algorithm Rigid? PIPJ arthrodesis Flexible? Restore MPJ and PIPJ congruency with tendon transfer(s) Goals Restore FDL function Joint congruency Correct transverse plane deformity
Literature Revision of failed foot surgery: a critical analysis n = 244 Most common reason for revision Transfer metatarsalgia Recurrent bunion Lesser digit deformity Satisfaction rates after revision Revisions- 176/244 24% with reservations 6% dissatisfied Kilmartin, J Foot Ankle Surg 41:5, 2002.
Literature Complications of digital and lesser metatarsal surgery Risk factors and co-morbidities Wound healing and infectious complications Smoking Implant failure and management Acute digital correction of longstanding toe deformities AVN of lesser metatarsals following surgery Floating and flail toe deformity Bibbo, et al., Clin Podiatr Med Surg 27:4, 2010.
Distal Metatarsal Osteotomy Indications Metatarsalgia Metatarsal parabola Plantar plate techniques Floating toe rates Migues, et al. Incidence Osteotomy alone 28.5% With digital correction 50.0% Highlander, et al. Incidence Floating toe 36.0% Migues, et al., Foot Ankle Int 25:9, 2004. Highlander, et al., Foot Ankle Spec 4:3, 2011.
Considerations Level of deformity Influence of adjacent digits Osseous versus soft tissue Malposition
Optimizing Results Recognizing pathology Anatomy Plantar plate injury? Rigidity Plane(s) of deformity Predictable outcomes Arthrodesis Tendon transfers FDL Trethowan, Lancet 205:5312, 1925. Taylor, J Bone Joint Surg 33B, 1951. EDB Forrester-Brown, J Bone Joint Surg 20A:1, 1938.
Case Scenario- Plantar Plate Direct plantar approach
Case Scenario- Plantar Plate Dorsal surgical approach Metatarsal osteotomy Plantar plate exposure Suture plantar plate Phalanx suture tunnels Tension repair Metatarsal fixation
Case Scenario- Plantar Plate Dorsal surgical approach Metatarsal osteotomy Plantar plate exposure Suture plantar plate Phalanx suture tunnels Tension repair Metatarsal fixation
Case Scenario- Plantar Plate Dorsal surgical approach Metatarsal osteotomy Plantar plate exposure Suture plantar plate Phalanx suture tunnels Tension repair Metatarsal fixation
Case Scenario- Plantar Plate Dorsal surgical approach Metatarsal osteotomy Plantar plate exposure Suture plantar plate Phalanx suture tunnels Tension repair Metatarsal fixation
Case Scenario- Plantar Plate Dorsal surgical approach Metatarsal osteotomy Plantar plate exposure Suture plantar plate Phalanx suture tunnels Tension repair Metatarsal fixation
Case Scenario- Plantar Plate Dorsal surgical approach Metatarsal osteotomy Plantar plate exposure Suture plantar plate Phalanx suture tunnels Tension repair Metatarsal fixation
Case Scenario- Plantar Plate Dorsal surgical approach Metatarsal osteotomy Plantar plate exposure Suture plantar plate Phalanx suture tunnels Tension repair Metatarsal fixation
Case Scenario- Plantar Plate What did I do? Repaired attenuated ligament Will it hold? Alternative FDL tendon transfer Pre-op Reinforce correction with steri-strips Post-op
Case Scenario- FDL Transfer Surgical approach PIPJ preparation FDL tendon Bone tunnel Tension tendon Bone anchor
Case Scenario- FDL Transfer Surgical approach PIPJ preparation FDL tendon Bone tunnel Tension tendon Bone anchor
Case Scenario- FDL Transfer Surgical approach PIPJ preparation FDL tendon Bone tunnel Tension tendon Bone anchor
Case Scenario- FDL Transfer Surgical approach PIPJ preparation FDL tendon Bone tunnel Tension tendon Bone anchor
Case Scenario- FDL Transfer Surgical approach PIPJ preparation FDL tendon Bone tunnel Tension tendon Bone anchor
Case Scenario- FDL Transfer Surgical approach PIPJ preparation FDL tendon Bone tunnel Tension tendon Bone anchor
Case Scenario- FDL Transfer Surgical approach PIPJ preparation FDL tendon Bone tunnel Tension tendon Bone anchor
Case Scenario- EDB Transfer Surgical approach Metatarsal bone tunnel Pass suture under deep intermetatarsal ligament Proximal phalanx bone tunnel Adjust tension 1 * * Downey, et al., in McGlamry s Comprehensive Textbook of Foot and Ankle Surgery, ed. Southerland, et al., Lippincott, Williams and Wilkins, Philadephia, 2013.
Case Scenario- EDB Transfer Surgical approach Metatarsal bone tunnel Pass suture under deep intermetatarsal ligament Proximal phalanx bone tunnel Adjust tension 1 * * Downey, et al., in McGlamry s Comprehensive Textbook of Foot and Ankle Surgery, ed. Southerland, et al., Lippincott, Williams and Wilkins, Philadephia, 2013.
Case Scenario- EDB Transfer Surgical approach Metatarsal bone tunnel Pass suture under deep intermetatarsal ligament Proximal phalanx bone tunnel Adjust tension 2 * * Downey, et al., in McGlamry s Comprehensive Textbook of Foot and Ankle Surgery, ed. Southerland, et al., Lippincott, Williams and Wilkins, Philadephia, 2013.
Case Scenario- EDB Transfer Surgical approach Metatarsal bone tunnel Pass suture under deep intermetatarsal ligament Proximal phalanx bone tunnel Adjust tension 3 * * Downey, et al., in McGlamry s Comprehensive Textbook of Foot and Ankle Surgery, ed. Southerland, et al., Lippincott, Williams and Wilkins, Philadephia, 2013.
Case Scenario- EDB Transfer Surgical approach Metatarsal bone tunnel Pass suture under deep intermetatarsal ligament Proximal phalanx bone tunnel Adjust tension * * Downey, et al., in McGlamry s Comprehensive Textbook of Foot and Ankle Surgery, ed. Southerland, et al., Lippincott, Williams and Wilkins, Philadephia, 2013.
Post-operatively Cicatrix contracture Splintage K-wire Bandaging Taping Splinting Weightbearing status Surgical shoe
Conclusions Accurate diagnosis Determine deforming factors Balance expectations Be definitive on surgical procedures Arthrodesis Tendon transfers
Annual Surgical Conference 2018 Thank You Zeeshan S. Husain, DPM, FACFAS, FASPS zee@alum.mit.edu