Essential Foot and Ankle Surgical Techniques: A Multidisciplinary Approach [1st ed.] 978-3-030-14777-8;978-3-030-14778-5

Table of contents :
Front Matter ....Pages i-xv
Preoperative Considerations, Surgical Planning, and Postoperative Protocols (Robert D. Santrock, Christopher F. Hyer)....Pages 1-13
Hallux Valgus Correction Osteotomies (Maria Romano McGann, David S. Buchan, Christopher F. Hyer)....Pages 15-25
Lapidus HAV Correction (W. Bret Smith, B. Collier Watson, Christopher W. Reb)....Pages 27-37
Hallux Interphalangeal Joint Arthrodesis and Jones Tendon Transfer (Jeffrey S. Weber)....Pages 39-49
Hammertoes and Claw Toes: Primary and Revision (Roberto A. Brandão, David Larson)....Pages 51-56
Plantar Plate Instability (Jeffrey E. McAlister, Mark A. Prissel)....Pages 57-68
1st MTP Fusion: Primary and Revision (William T. DeCarbo, Michael D. Dujela)....Pages 69-83
Interpositional Arthroplasty for the First Metatarsophalangeal Joint (Patrick E. Bull, James M. Cottom, Geoffrey Landis)....Pages 85-92
First Metatarsal Cheilectomy and Osteochondral Defect Treatments (Bryan Van Dyke, Terrence M. Philbin)....Pages 93-99
Neuroma (Travis Langan, Adam Halverson, David Goss Jr.)....Pages 101-108
Turf Toe and Sesamoid Injuries (Matthew M. Buchanan)....Pages 109-119
Tarsometatarsal Joint Arthrodesis (Mark A. Prissel, Jeffrey E. McAlister)....Pages 121-135
Cotton Osteotomy (Jeffrey S. Weber)....Pages 137-148
Fourth and Fifth Tarsometatarsal Degenerative Joint Disease Management (Maria Romano McGann, Bryan Van Dyke, Gregory C. Berlet)....Pages 149-151
Tibialis Anterior Tendon Ruptures (Corey M. Fidler, Patrick E. Bull)....Pages 153-156
Charcot Midfoot (W. Bret Smith, Justin Daigre)....Pages 157-166
Naviculocuneiform Joint Fusion (Jeffrey E. McAlister, Roberto A. Brandão, Bryan Van Dyke, Maria Romano McGann, Christopher F. Hyer)....Pages 167-174
Posterior Tibial Tendon Repair: Kidner, FDL Transfer, and Medial Displacement Calcaneal Osteotomy (Kyle S. Peterson, Michael D. Dujela)....Pages 175-187
Lateral Column Lengthening (Kyle S. Peterson, David Larson, Roberto A. Brandão)....Pages 189-196
The Medial Double Arthrodesis (Bradly W. Bussewitz, Christopher W. Reb, David Larson)....Pages 197-208
Isolated Talonavicular Joint Arthrodesis (Jeffrey E. McAlister, Gregory C. Berlet)....Pages 209-215
Isolated Subtalar Joint Arthrodesis (Michael D. Dujela, Ryan T. Scott, Matthew D. Sorensen, Mark A. Prissel)....Pages 217-231
Two-Incision Triple Arthrodesis (J. George DeVries)....Pages 233-248
Tarsal Coalition (Daniel J. Cuttica, Thomas H. Sanders)....Pages 249-259
Achilles Procedures (Gregory C. Berlet, Roberto A. Brandão, Bryan Van Dyke)....Pages 261-273
Ankle Arthrodesis: Open Anterior and Arthroscopic Approaches (Michael D. Dujela, Christopher F. Hyer)....Pages 275-290
Tibiotalocalcaneal Arthrodesis (J. George DeVries, Matthew D. Sorensen)....Pages 291-306
Cavus Foot Reconstruction (Jeffrey E. McAlister, Mark A. Prissel, Christopher F. Hyer, Gregory C. Berlet, Terrence M. Philbin, Patrick E. Bull)....Pages 307-323
Surgical Treatment of Peroneal Tendon Disorders (Terrence M. Philbin, B. Collier Watson, Christopher F. Hyer)....Pages 325-336
Plantar Fasciitis and Tarsal Tunnel (Corey M. Fidler, Gregory C. Berlet)....Pages 337-341
Supple Equinus, Equinovarus, and Drop Foot Surgical Strategies (Roberto A. Brandão, Maria Romano McGann, Patrick E. Bull)....Pages 343-355
TAR Primary Options (W. Bret Smith, P. Pete S. Deol)....Pages 357-364
Revision Total Ankle Arthroplasty (Christopher W. Reb, Gregory C. Berlet)....Pages 365-376
Surgical Management of Talar Avascular Necrosis (Jeffrey S. Weber)....Pages 377-390
Hindfoot and Ankle Charcot Reconstruction (Roberto A. Brandão, Justin Daigre, Christopher F. Hyer)....Pages 391-410
Ankle and Subtalar Joint Arthroscopy (Ryan T. Scott, Mark A. Prissel)....Pages 411-420
Open Treatment of Osteochondral Lesions of the Talus (Daniel J. Cuttica, Christopher W. Reb)....Pages 421-429
Collateral Ankle Ligament Repair (Ryan T. Scott, James M. Cottom, Matthew D. Sorensen, Mark A. Prissel)....Pages 431-445
Amputations (Premjit Pete S. Deol, Robert D. Santrock)....Pages 447-457
Grafting and Biologics (Ryan T. Scott, Christopher F. Hyer, Gregory C. Berlet, Terrence M. Philbin, Patrick E. Bull, Mark A. Prissel)....Pages 459-467
Back Matter ....Pages 469-482

Citation preview

Essential Foot and Ankle Surgical Techniques A Multidisciplinary Approach Christopher F. Hyer Gregory C. Berlet Terrence M. Philbin Patrick E. Bull Mark A. Prissel Editors

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Essential Foot and Ankle Surgical Techniques

Christopher F. Hyer  •  Gregory C. Berlet Terrence M. Philbin  •  Patrick E. Bull Mark A. Prissel Editors

Essential Foot and Ankle Surgical Techniques A Multidisciplinary Approach

Editors Christopher F. Hyer, DPM, MS, FACFAS Fellowship Director Orthopedic Foot & Ankle Center Worthington, OH USA Terrence M. Philbin, DO, FAOAO Fellowship Director Orthopedic Foot & Ankle Center Worthington, OH USA

Gregory C. Berlet, MD, FRCS(C), FAOA Orthopedic Foot & Ankle Center Worthington, OH USA Patrick E. Bull, DO, FAOAO Orthopedic Foot & Ankle Center Worthington, OH USA

Mark A. Prissel, DPM, FACFAS Orthopedic Foot & Ankle Center Worthington, OH USA

ISBN 978-3-030-14777-8    ISBN 978-3-030-14778-5 (eBook) https://doi.org/10.1007/978-3-030-14778-5 © Springer Nature Switzerland AG 2019 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Foreword

A dramatic evolution in our understanding of foot and ankle disorders, both its pathophysiology and treatment, has occurred over recent years. Both of us have been involved in a paradigm shift of foot and ankle management from one fairly conservative and nonoperative, even reactionary, to a more proactive mindset that attempts to preserve motion in the active individual, lessening long-term disabilities. Our collective 55+ years of experience in this field have witnessed advances in not only the basics of patient management but also technological opportunities. Further, our ability to teach others based on our past experiences has expanded with the number and quality of foot and ankle fellowships, subspecialty societies, industry partnerships, and even social media. All of these changes have helped us take better care of our patients, and quite simply, we are better providers than we were years ago. However, we have also been humbled in this learning experience—the absolute truth about foot and ankle surgery is that “this stuff is not easy!!!” The reality of repairing an extremity that repetitively hits an uneven ground with full body weight is one that challenges us—whenever we are certain of a successful treatment regiment, our patients prove us wrong. There is a reason that this humbling nature of foot and ankle surgery is particularly relevant when asked to introduce this comprehensive text, Essential Foot and Ankle Surgical Techniques. The reason is a purpose: The physicians at The Orthopedic Foot and Ankle Center in Columbus, Ohio, decided a number of years ago that the best way to help our collective patients was to create a provider group with multiple backgrounds. From educational backgrounds that encompass MDs, DOs, and DPMs to the necessary ancillary expertise of prosthetists, orthotists, and physical therapists, this truly represents a “collaboration.” Patients are best managed with a “team approach,” and this text represents that. This group of talented practitioners has created a venue where all views and backgrounds are valued. The chapters delve into difficult topics and treatment options, introducing a number of management options influenced by the authors’ backgrounds, but with the priority being the patients’ best interest. That is the value and the timeliness of this text. In a time where there is a stated need to celebrate excellence, each chapter comes at the reader from a purpose and desire to aid us in this difficult career choice of foot and ankle. We applaud the editors and all of the contributors for this true multidisciplinary collaboration. Charlotte, NC, USA 

W. Hodges Davis, MD Robert B. Anderson, MD v

Preface

The specialty of foot and ankle surgery is a diverse amalgamation of orthopedic surgical principles, biomechanics and kinesiology, sports medicine, physical therapy and rehabilitation, as well as the psychology of patient and surgeon expectations. This is also a unique specialty because surgeons of different training backgrounds, including Doctors of Podiatric Medicine (DPM), Doctors of Osteopathic Medicine (DO), and Doctors of Allopathic Medicine (MD), practice it nationally and internationally. It is our belief that when knowledge and experience is shared among these diverse surgeons, the specialty of foot and ankle surgery, and ultimately patient care, continues to improve. It is for these reasons that we have brought together these surgeons and past fellows to produce this innovative and unique text. This textbook is a reflection of our unique foot and ankle specialty practice and our surgical fellowship program at The Orthopedic Foot and Ankle Center in Columbus, Ohio. Our practice is comprised of fellowship-trained MD, DO, and DPM foot and ankle surgeons dedicated to the subspecialty of foot and ankle surgery. We practice in a fully collaborative environment encompassing all aspects of education, research, and patient care—with the primary goal of constantly improving patient care and surgical outcomes. We continue to “spread the word” nationally and internationally through our interaction with other surgeon colleagues and are humbled to see many like-­ minded surgeons who understand the benefit of this collaborative approach. We are honored to have our dear friends, mentors, and world-renowned giants in foot and ankle surgery—Drs. Robert Anderson and Hodges Davis— contribute the Foreword of this text. We individually and collectively learned so much from them both; thus, it is an absolute honor to have their words of wisdom attached to this textbook. In this text, we have tried to reveal our unique multidisciplinary perspective and approach to the most common foot and ankle surgical topics. We believe that both careful preoperative planning and discussion among the treatment team are key tenets of our multidisciplinary approach. This leads to deliberate and careful consideration of operative efficiency and excellence so that the day of surgery is simply the execution of a well-thought-out plan. You will note “callouts” throughout the text of key steps and operative “pearls” to assist with the efficiency and performance of critical surgical steps.

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Preface

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This textbook is not meant to be a historical review or an all-encompassing encyclopedia of foot and ankle pathologies; rather, it is a careful description of current techniques and approaches to the most common surgical ­treatments. We have attempted to reveal “what works well in our hands” and the evolution of techniques that produce consistently successful outcomes. We hope you find the direct and focused approach refreshingly practical and useful in the care of your patients. Worthington, OH, USA

Christopher F. Hyer

Contents

1 Preoperative Considerations, Surgical Planning, and Postoperative Protocols������������������������������������������������������������   1 Robert D. Santrock and Christopher F. Hyer 2 Hallux Valgus Correction Osteotomies������������������������������������������  15 Maria Romano McGann, David S. Buchan, and Christopher F. Hyer 3 Lapidus HAV Correction����������������������������������������������������������������  27 W. Bret Smith, B. Collier Watson, and Christopher W. Reb 4 Hallux Interphalangeal Joint Arthrodesis and Jones Tendon Transfer ������������������������������������������������������������  39 Jeffrey S. Weber 5 Hammertoes and Claw Toes: Primary and Revision��������������������  51 Roberto A. Brandão and David Larson 6 Plantar Plate Instability������������������������������������������������������������������  57 Jeffrey E. McAlister and Mark A. Prissel 7 1st MTP Fusion: Primary and Revision����������������������������������������  69 William T. DeCarbo and Michael D. Dujela 8 Interpositional Arthroplasty for the First Metatarsophalangeal Joint��������������������������������������������������������������  85 Patrick E. Bull, James M. Cottom, and Geoffrey Landis 9 First Metatarsal Cheilectomy and Osteochondral Defect Treatments����������������������������������������������������������������������������������������  93 Bryan Van Dyke and Terrence M. Philbin 10 Neuroma�������������������������������������������������������������������������������������������� 101 Travis Langan, Adam Halverson, and David Goss Jr. 11 Turf Toe and Sesamoid Injuries������������������������������������������������������ 109 Matthew M. Buchanan 12 Tarsometatarsal Joint Arthrodesis ������������������������������������������������ 121 Mark A. Prissel and Jeffrey E. McAlister 13 Cotton Osteotomy���������������������������������������������������������������������������� 137 Jeffrey S. Weber ix

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14 Fourth and Fifth Tarsometatarsal Degenerative Joint Disease Management�������������������������������������������������������������� 149 Maria Romano McGann, Bryan Van Dyke, and Gregory C. Berlet 15 Tibialis Anterior Tendon Ruptures������������������������������������������������ 153 Corey M. Fidler and Patrick E. Bull 16 Charcot Midfoot ������������������������������������������������������������������������������ 157 W. Bret Smith and Justin Daigre 17 Naviculocuneiform Joint Fusion���������������������������������������������������� 167 Jeffrey E. McAlister, Roberto A. Brandão, Bryan Van Dyke, Maria Romano McGann, and Christopher F. Hyer 18 Posterior Tibial Tendon Repair: Kidner, FDL Transfer, and Medial Displacement Calcaneal Osteotomy�������������������������� 175 Kyle S. Peterson and Michael D. Dujela 19 Lateral Column Lengthening��������������������������������������������������������� 189 Kyle S. Peterson, David Larson, and Roberto A. Brandão 20 The Medial Double Arthrodesis������������������������������������������������������ 197 Bradly W. Bussewitz, Christopher W. Reb, and David Larson 21 Isolated Talonavicular Joint Arthrodesis �������������������������������������� 209 Jeffrey E. McAlister and Gregory C. Berlet 22 Isolated Subtalar Joint Arthrodesis������������������������������������������������ 217 Michael D. Dujela, Ryan T. Scott, Matthew D. Sorensen, and Mark A. Prissel 23 Two-Incision Triple Arthrodesis ���������������������������������������������������� 233 J. George DeVries 24 Tarsal Coalition�������������������������������������������������������������������������������� 249 Daniel J. Cuttica and Thomas H. Sanders 25 Achilles Procedures�������������������������������������������������������������������������� 261 Gregory C. Berlet, Roberto A. Brandão, and Bryan Van Dyke 26 Ankle Arthrodesis: Open Anterior and Arthroscopic Approaches �������������������������������������������������������������������������������������� 275 Michael D. Dujela and Christopher F. Hyer 27 Tibiotalocalcaneal Arthrodesis ������������������������������������������������������ 291 J. George DeVries and Matthew D. Sorensen 28 Cavus Foot Reconstruction ������������������������������������������������������������ 307 Jeffrey E. McAlister, Mark A. Prissel, Christopher F. Hyer, Gregory C. Berlet, Terrence M. Philbin, and Patrick E. Bull 29 Surgical Treatment of Peroneal Tendon Disorders ���������������������� 325 Terrence M. Philbin, B. Collier Watson, and Christopher F. Hyer

Contents

Contents

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30 Plantar Fasciitis and Tarsal Tunnel������������������������������������������������ 337 Corey M. Fidler and Gregory C. Berlet 31 Supple Equinus, Equinovarus, and Drop Foot Surgical Strategies������������������������������������������������������������������������������������������ 343 Roberto A. Brandão, Maria Romano McGann, and Patrick E. Bull 32 TAR Primary Options �������������������������������������������������������������������� 357 W. Bret Smith and P. Pete S. Deol 33 Revision Total Ankle Arthroplasty ������������������������������������������������ 365 Christopher W. Reb and Gregory C. Berlet 34 Surgical Management of Talar Avascular Necrosis���������������������� 377 Jeffrey S. Weber 35 Hindfoot and Ankle Charcot Reconstruction�������������������������������� 391 Roberto A. Brandão, Justin Daigre, and Christopher F. Hyer 36 Ankle and Subtalar Joint Arthroscopy������������������������������������������ 411 Ryan T. Scott and Mark A. Prissel 37 Open Treatment of Osteochondral Lesions of the Talus�������������� 421 Daniel J. Cuttica and Christopher W. Reb 38 Collateral Ankle Ligament Repair ������������������������������������������������ 431 Ryan T. Scott, James M. Cottom, Matthew D. Sorensen, and Mark A. Prissel 39 Amputations ������������������������������������������������������������������������������������ 447 Premjit Pete S. Deol and Robert D. Santrock 40 Grafting and Biologics�������������������������������������������������������������������� 459 Ryan T. Scott, Christopher F. Hyer, Gregory C. Berlet, Terrence M. Philbin, Patrick E. Bull, and Mark A. Prissel Index���������������������������������������������������������������������������������������������������������� 469

Contributors

Gregory  C.  Berlet, MD, FRCS(C), FAOA Orthopedic Foot & Ankle Center, Worthington, OH, USA Roberto  A.  Brandão, DPM, AACFAS The Centers for Advanced Orthopaedics, Orthopaedic Associates of Central Maryland Division, Catonsville, MD, USA David  S.  Buchan, DPM Orthopedic Foot & Ankle Center, Worthington, OH, USA Matthew M. Buchanan, MD  Center for Sports Medicine and Orthopaedics, Chattanooga, TN, USA Patrick  E.  Bull, DO  Orthopedic Foot & Ankle Center, Worthington, OH, USA Bradly  W.  Bussewitz, DPM Steindler Orthopedic Clinic, Iowa City, IA, USA James  M.  Cottom, DPM, FACFAS Florida Orthopedic Foot & Ankle Center, Sarasota, FL, USA Daniel J. Cuttica, DO  Assistant Professor of Clinical Orthopaedic Surgery, Georgetown University School of Medicine, The Orthopaedic Foot & Ankle Center, a Division of Centers for Advanced Orthopaedics, Falls Church, VA, USA Justin Daigre, MD  Decatur Morgan Hospital, Decatur Orthopaedic Clinic, Decatur, AL, USA William  T.  DeCarbo, DPM St. Clair Hospital, Department of Podiatric Surgery, Pittsburgh, PA, USA P. Pete S. Deol, DO  Panorama Orthopedics & Spine Center, Section of Foot & Ankle, Golden, CO, USA J. George DeVries, DPM  BayCare Clinic, Manitowoc, WI, USA Michael  D.  Dujela, DPM, FACFAS Washington Orthopaedic Center, Centralia, WA, USA Corey M. Fidler, DPM  Carilion Clinic, Department of Orthopaedic Surgery, Roanoke, VA, USA xiii

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David  Goss Jr., DO  Orthopedic Foot and Ankle Center, Orthopedic Foot and Ankle Surgery, Worthington, OH, USA Adam Halverson, DO  Orthopedic Foot and Ankle Center, Orthopedic Foot and Ankle Surgery, Worthington, OH, USA Christopher  F.  Hyer, DPM, MS, FACFAS   Orthopedic Foot & Ankle Center, Worthington, OH, USA Geoffrey  Landis, DO Northwest Medical Center/Oro Valley Hospital, Department of Orthopedic Surgery, Tucson, AZ, USA Travis Langan, DPM  Orthopedic Foot and Ankle Center, Orthopedic Foot and Ankle Surgery, Worthington, OH, USA David  Larson, DPM Steward Health Care, Department of Podiatry, Glendale, AZ, USA Jeffrey  E.  McAlister, DPM Arcadia Orthopedics and Sports Medicine, Phoenix, AZ, USA Maria Romano McGann, DO  Romano Orthopaedic Center, Oak Park, IL, USA Kyle S. Peterson, DPM, FACFAS  Suburban Orthopaedics, Division of Foot and Ankle Surgery, Bartlett, IL, USA Terrence M. Philbin, DO  Orthopedic Foot & Ankle Center, Worthington, OH, USA Mark A. Prissel, DPM  Orthopedic Foot & Ankle Center, Worthington, OH, USA Christopher W. Reb, DO  University of Florida, Department of Orthopedics, Division of Foot and Ankle Surgery, Gainesvilles, FL, USA Thomas  H.  Sanders, MD Assistant Professor of Clinical Orthopaedic Surgery, Georgetown University School of Medicine, The Orthopaedic Foot & Ankle Center, a Division of Centers for Advanced Orthopaedics, Falls Church, VA, USA Robert  D.  Santrock, MD West Virginia University/Ruby Memorial Hospital, Department of Orthopaedics, Robert C.  Byrd Health Sciences Center, Morgantown, WV, USA Ryan T. Scott, DPM  The CORE Institute, Phoenix, AZ, USA W.  Bret  Smith, DO, MS  Foot and Ankle Division Palmetto Health-USC Orthopedic Center, Palmetto Health, Department of Orthopedic Surgery, Lexington, SC, USA Matthew D. Sorensen, DPM, FACFAS  Weil Foot and Ankle Institute, Foot & Ankle Surgery, Chicago, IL, USA

Contributors

Contributors

xv

Bryan Van Dyke, DO  Summit Orthopaedics, Idaho Falls, ID, USA B. Collier Watson, DO  The Hughston Clinic, Columbus, GA, USA Jeffrey  S.  Weber, DPM  Birch Tree Foot and Ankle Specialists, Traverse City, MI, USA

1

Preoperative Considerations, Surgical Planning, and Postoperative Protocols Robert D. Santrock and Christopher F. Hyer

1.1

Introduction

Modern medicine has provided tremendous tools to help a broad spectrum of patients with a variety of diseases and deformities. Certainly, today’s foot and ankle surgeon has benefited from technology and advancements that have broadened the reach of our services. However, technology can also lull any surgeon into a feeling of comfort and complacency. Perhaps among all of the disciplines of orthopedics, foot and ankle reconstruction is uniquely at risk for a greater level and greater frequency of complications based on the patient’s physiology, the weight-bearing stress on the postoperative limb, and often multilevel deformities. Therefore, a systematic approach to preparing for foot and ankle surgery is paramount to ensuring a successful outcome for each and every patient. In this chapter, we will first lay out some of our specific preoperative optimization parameters. These are guidelines that we use based on our best understanding of the available literature and based on our collective experience.

R. D. Santrock (*) West Virginia University/Ruby Memorial Hospital, Department of Orthopaedics, Robert C. Byrd Health Sciences Center, Morgantown, WV, USA e-mail: [email protected] C. F. Hyer Orthopedic Foot & Ankle Center, Worthington, OH, USA

The remainder of the chapter will focus on ­several key perioperative steps: the preoperative indications and planning conference, the day of surgery checklist and surgical team huddle, and the use of postoperative protocols.

1.2

Preoperative Optimization

Nutritional Status  Many patients appear grossly healthy but may be subtly malnourished, especially if they have a chronic disease. As a matter of fact, many diabetic patients are malnourished [1]. This is reflected in such readings as prealbumin, albumin, and total lymphocyte counts. Knowing these numbers can be predictive of mortality and morbidity of surgery. For example, the below-the-knee amputation (BKA) is a well-­ known procedure that has a significant mortality risk. However, this risk is not inherent to the procedure but rather a reflection of the patient’s overall health. The nutritional status parallels the patient’s health and therefore can serve as a risk assessment of a pending surgery. It is in general recommended that the lower extremity surgical patient has a preoperative albumin of >2.5 g/dL and a total lymphocyte count of >1500/μL in order to proceed with a significant foot and ankle surgery [2]. These numbers are only a guideline and based on a patient with chronic disease such as diabetes, who is facing a serious surgery such as a BKA.

© Springer Nature Switzerland AG 2019 C. F. Hyer et al. (eds.), Essential Foot and Ankle Surgical Techniques, https://doi.org/10.1007/978-3-030-14778-5_1

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Blood Glucose Control  To further elaborate on the importance of overall health, the diabetic patient needs additional parameters to be met for elective surgery. An ideal diabetic patient will have an A1c reading at 7.0% or less. Since the A1c percentage is a reading over time, it may be hard to see that direct change during a hospitalization. Therefore, it is generally recommended to have a blood glucose reading to be a normal as possible (less than 150 mg/dL) to optimize healing. This is best achieved to have the admitting medical service remove all maintenance diabetes medications and have the patient managed with sliding scale insulin if it is a relatively urgent situation. However, scheduled elective foot and ankle cases probably should be delayed until the A1c reflects good blood glucose control. At an A1c of 7.0%, there is likely no physiologic damage occurring, and therefore the patient is best prepared to heal from elective surgery [3–5]. In cases with chronic poor glycemic control, a consult with endocrinology may be warranted. Obviously, nonelective cases such as infection management may need to move forward despite elevated A1c levels but typically are done with hospitalization and medical team management to maximally optimize the patient.

R. D. Santrock and C. F. Hyer

An ABI of >1.25 indicates a possibility of calcified, non-compliant vessels. Therefore, if this supranormal value is present, triphasic waveforms are needed to be visualized on the Doppler to ensure vessel response. However, if the ABI is 1.25, then this warrants arteriography to evaluate and/or perform intervention on the proximal vessels prior to foot and ankle surgery. A vascular medicine consult and clearance for elective surgery is often obtained in patients considered at risk and with concern of significant peripheral artery disease.

Anticoagulation Medications/DVT Risks  There are a number of patients on anticoagulant medications today. These drugs are used for a variety of ailments such as atrial fibrillation and prior cerebral vascular events. Most all of the m ­ edications can cause problems in the immediate postoperative period. The main local concern is postoperative bleeding that causes hematoma and/or skin necrosis from internal pressure. Our recommendation is to stop all anticoagulants if possible except for 81  mg aspirin. However, we ask the prescribing physician to approve and manage this change. Typically if the prescribing physician requires a substitute, we only agree to Lovenox Vascular Assessment  It is appropriate to assume (enoxaparin). It is our opinion that this is the only that surgery on the foot and ankle is risky as it drug in my opinion that has a short enough half-­ pertains to vascular status. After all these invasive life to halt a dangerous development quickly. The procedures are being performed on the most newer drugs of Xarelto (rivaroxaban), Eliquis remote portion of the body, furthest from the (apixaban), and Arixtra (fondaparinux) all claim heart. In a healthy patient who is having a rela- a short half-life, but our experience is that this tively simple surgery, a normal pulse exam may is not uniform. Nor do these newer drugs have be enough to feel safe for surgical healing. a reversal agent; therefore, our recommendation However, larger surgeries (bigger dissections or is to lobby the prescribing physician away from incisions) or surgeries with a prolonged tourni- using these in the first 3 weeks postoperatively. quet time (2 hours) may require a more thorough DVT risk stratification is a subject with a wide evaluation. This is also true for patients who have range of methods and opinions. The AOFAS and a personal risk of peripheral vascular disease the AAOS are in agreement to follow the local (PVD). While a patient with PVD may be non-­ standards of care and to stratify patients accordsymptomatic preoperatively, the increased physi- ing to your hospital’s risk assessment. In general, ologic demand of the surgical healing may exceed if we have patients needing prescriptions beyond the capabilities of the narrowed arteries postop- 325  mg of aspirin, we recommend that the prieratively. In these patients, it is recommended to mary care physician or hematologist pre-certify start with an ankle-brachial index (ABI). An ABI and manage this medication. And again, we recof >0.5 should be sufficient for healing [2]. ommend Lovenox (enoxaparin) for the quick

1  Preoperative Considerations, Surgical Planning, and Postoperative Protocols

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body, and every foot and ankle surgery will produce additional swelling. Therefore, the patient with pre-existing chronic venous insufficiency (CVI) should be approached with additional caution. There are two issues with CVI: increased infection risk and increased wound complications. The latter issue is obvious; the CVI patient is more prone to drainage. This drainage is acidic Rheumatoid Arthritis  Today’s treatment of and thus caustic to the skin edge; this leads to rheumatoid arthritis depends much more heavily skin edge necrosis and wound dehiscence. To on the modern disease altering drugs. However, avoid this issue, it is recommended to have meticthese drugs are significant immunosuppressant ulous skin handling and closure. We recommend compounds. Furthermore, these drugs also stringent elevation postoperatively. And finally, it decrease the normal healing cascade needed to is also our habit to bring these patients into the recover from surgery. For patients on disease-­ office for more frequent dressing changes and modifying antirheumatics drugs (DMARD), it is wound checks. We have found Unna wraps recommended to work with the prescribing rheu- ­beneficial on these patients, changing the wrap matologist to create the best “window” or gap in weekly. dosing to give the patient the lowest risk of infection and wound healing complications. As a The other issue of increased infection risk is general concept, the risk diminishes greatly once somewhat related to the aforementioned increased the wound has healed, usually within 3 weeks of wound complications. However, there are other the procedure. Additional time may be taken reasons to be concerned for increased infection when joint arthrodesis and fracture healing is risk: an increased epithelial layer, an increased concerned. surface flora, and chronic draining wounds. The The traditional medications of prednisone, CVI patient is often using Unna wraps or commethotrexate, and plaquenil are utilized less pression stockings. These devices prevent the often than in the past. However, these drugs too natural sloughing of the epithelial layer of the can impede postoperative healing. There are no skin. This simply increases the thickness of the definitive recommendations for stopping these epithelial layer, which is harder to penetrate with medications in the perioperative period; again, sterilization prep solutions. This thicker epitheconsult with the prescribing physician. Often if lium provides a higher bacterial load or surface patients are on chronic prednisone therapy, they flora. The same issue exists with chronic wounds. have fairly resistant disease and may not be able The chronic wounds of CVI are almost always to titrate off altogether. It is recommended to con- contaminated with multiple species of bacteria. sult the treating rheumatologist to get to the low- Our recommendation is to do a “pre-scrub” and est does possible in an effort to decrease wound exfoliation, if needed, and then perform the stanhealing complications. Typically these patients dard surgical prep. Additionally it is recommay require a dose of hydrocortisone prior to sur- mended to use a bacteriostatic or bactericidal gery, but we leave the decision for the onetime dressing postoperatively. The dressings with “stress dose” steroid administration up to the metal ions tend to be very effective in assisting in anesthesiologist. Typically medications such as prevention of postoperative wound infections. methotrexate and plaquenil can be carried through surgery without significant increased Nicotine Use  As with all surgeries, nicotine use healing risk. is heavily discouraged. There is abundant scientific evidence that nicotine is detrimental to surgiChronic Edema  The foot and ankle region is cal healing  – both to skin healing and to bone already the most gravity-dependent part of the healing. Nicotine is a vasoconstrictor and an half-life. Risk factors such as prior DVT, tobacco use, and the need for prolonged postoperative immobilization are all taken into account when deciding on the need for chemical prophylaxis. Mechanical options such as anti-embolism stockings and pneumatic calf cuffs are also often use in conjunction with chemical agents.

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inhibitor to angiogenesis; therefore all forms of nicotine should be avoided during the perioperative period. By technical measure, nicotine metabolites are detectible in the blood for 6  weeks post last exposure. And secondhand smoke is indeed nicotine exposure. It is important to properly counsel and document the education of the patient as to the detrimental effects and increased risk of continued use of nicotine products.

longed crutch use are helpful, such as knee scooters and wheelchairs with elevated leg rests. In many cases, a home health agencies and occupational therapist can be sent out to the patients home prior to surgery to assess the postoperative equipment needs such as shower chairs, bedside commodes, and home entry assistive ramps.

1.3 Caution is recommended with patients with nicotine consumption/exposure due to the deleterious effects on healing. In some specific surgeries with high-risk incisions (i.e., anterior total ankle arthroplasty), even remote history of nicotine use may be dangerous. In a study by Whalen et al. in 2010, it was shown that the anterior total ankle arthroplasty approach had a 35% chance of surgical wound complication if a patient had >12ppy smoking history, no matter how remote the patient had smoked [6]. Referral to tobacco cessation programs, referral to primary care physician for pharmacologic management and simply delay of surgery to allow patients to quit are all plausible options in elective cases. Social Support  All foot and ankle surgeries produce a significant life disruption, merely because our surgeries affect locomotion. No matter how strong and health a patient is preoperatively, some preparation is needed to accommodate decreased locomotion during recovery. In some patients this may require a change in living quarters or a hiatus in work. Obviously some surgeries, such as the BKA, require more planning than others. The patient and family should be given an opportunity to meet with Social Services and Prosthetic Services prior to the BKA when possible. This eases anxiety and allows for equipment planning. Careful consideration and discussion with the patient about the postoperative restrictions should be had with the patient and family if possible. In non-weight-bearing recoveries, options to pro-

The Surgical Team Communication

Communication with the entire surgical team is not a one-time event. It is a process that has many episodes. Maintaining this communication is vital to the success of any foot and ankle surgery. Our experience has shown that this process extends beyond the surgeon and the operation room staff but also includes administrative assistants, surgical schedulers, clinic staff, insurance specialists, durable medical good suppliers, prosthetists, physical therapists, anesthesiologists, medical consultants, residents/fellows, orthopedic sales representatives, and hospital administration. Below are three tools we use to assist in communication. The Screening Checklist  Much akin to the preflight checklist commercial pilots use just before takeoff, this tool is used before booking a patient for surgery. The purpose of this checklist is to screen for deficits in the preoperative optimization factors outlined above. Therefore, if a deficiency is found, it can be addressed before the patient is placed onto the operation room schedule and before a preventable complication occurs (Fig. 1.1). The Surgical Request  The second tool is the s­ urgical request form. This form is used to communicate with the surgical schedulers, medical consultants, anesthesiologist, the operating room, the orthopedic sales representative, insurance specialists, and residents/fellows. This can be used to dictate an “operative plan” that includes

WVU Foot & Ankle Mini Screening

1  Preoperative Considerations, Surgical Planning, and Postoperative Protocols

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1. Do you smoke, chew, or use vapor?

YES

NO

2. Have you ever smoked?

YES

NO

a. if yes, did you quit < 6 weeks ago?

YES

NO

b. If yes, was it for more than 12 years?

YES

NO

3. Are you around 2nd hand smoke?

YES

NO

4. Do you have diabetes?

YES

NO

YES

NO

YES

NO

YES

NO

6. Do you take anticoagulants?

YES

NO

7. Have you ever had a blood clot in the leg or lungs?

YES

NO

8. Has anyone in your family ever had a blood clot?

YES

NO

9. Have you ever been diagnosed with PVD?

YES

NO

10. Are there scars on the operative foot?

YES

NO

11. Are the pulses to the operative foot normal?

NO

YES

12. Are you prepared to come to WVU for all of your care?

NO

YES

13. Do you agree in the use of a surgical team, including residents?

NO

YES

14. Are you filed under WC?

YES

NO

15. Are you signed up for MyChart?

NO

YES

a. If yes, was the A1c within 3 months at 7.0 or higher? 5. Do you take NSAIDs, Steroids, BC, HRT, or drugs for RA? a. If yes, are you prepared to have these stopped?

Fig. 1.1  Example of a screening tool used to schedule elective foot and ankle surgery

the information on this form and an indication for the procedure. This dictation is a powerful tool in pre-authorizing the surgery. It is also a fantastic tool in communicating with the residents and ­fellows as they prepare for the case (Figs. 1.2 and 1.3), and we use this sheet intraoperatively as a

final sign-off tool as to correct patient, side and site of surgery, and the surgical plan. The Patient Passport  Written patient instructions are an important document to supplement the preoperative surgeon-patient meeting. This

R. D. Santrock and C. F. Hyer

6 Fig. 1.2 Surgical request worksheet used to make a preoperative dictation (WVU)

F&A PRE-OP PLAN Date of Service: Indication for Surgery (diagnosis): Conservative Measures (and how long?): Screening Tool Abnormalities: Planned Procedure: Operative Side: Planned Admission Status: Planned WB Status: Estimated Surgical Time: Anesthesia Type: Position: Fluoroscopy Type: Equipment & Implants: Planned Bone Stimulator: Special Surgery Notes (i.e. hold antibiotics, no betadine, special date requested, etc.): Special H&P Notes (i.e. medical clearance, cardiac clearance, A1c, Albumin, Nicotine, ABI, WBCT, Prophecy CT, Bootwalker, special anticoagulation arranged by PCP, stop certain drugs, etc.): Planned Follow-Up: Pre-Operative CPT Codes: Signed

document should be concise and clear on the postoperative instructions that the patient is expected to follow. The appropriate contact phone numbers should be included. This document can be expanded to give some rationale behind certain restrictions, such as an explanation of the addictive nature of narcotics or the deleterious effects of secondhand smoke on

h­ ealing. We have made this into an interactive booklet. In some centers this is called the patient passport, and we encourage the patient to bring this booklet with them to all interactions and appointments in the perioperative period. This creates a sense of “ownership” for the patient, and this has been a positive tool in the success of our patients after surgery.

1  Preoperative Considerations, Surgical Planning, and Postoperative Protocols

Fig. 1.3  Surgical request and planning sheet (OFAC)

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1.4

 he Preoperative Indications T and Planning Conference

It is our belief that a planning conference is beneficial to be performed once per week and is a vitally important tool. During this conference, each case is reviewed with members of the ­surgical team and other attending surgeons. This process serves an educational function for administrative assistants, schedulers, orthopedic sales representatives, and residents and fellows. It is also an important efficiency and safety check that the proper equipment has been requested and the surgical consent matches the request form and the clinical documentation. This conference also serves as a final “curb side consult” with partners and fellow surgeons to discuss difficult cases and get outside opinions to benefit the overall result. It is not infrequent that a fresh and unbiased perspective from a colleague reviewing the case may bring out an important consideration that may alter or adjust the surgical plan. In our busy practices where we might not see our partners all week, the preoperative planning conference is one that is rarely missed. Even in cases when the attending can’t make the live conference, it is always “made-up” after the fact with the residents and fellows who attended the live event to confirm any changes or discussion. The surgical planning documents and notes are carried forward from the planning conference and into the operating room on the day of surgery. During the room preparation, the surgical request sheet, the pertinent last clinical note with the surgical plan and the key images from the patient’s latest imaging studies are all posted on the view box or easy to view location. This is reviewed again during room turnover and is available for all involved in the case to easily review as well (Figs. 1.4, 1.5, 1.6, 1.7, 1.8, and 1.9). During the “time-out process” with ­everyone in the room, we review that the images,

Fig. 1.4  Case example, preoperative lateral ankle x-ray

Fig. 1.5  Case example, preoperative lateral CT image

surgical booking sheet, last clinical note, ­consent, surgeon signature on the limb, and the patient wristband ID all match up. This is the final safety check before the case starts and also  again gets the entire team focused on the surgical plan.

1  Preoperative Considerations, Surgical Planning, and Postoperative Protocols

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Fig. 1.6  Case example, preoperative AP ankle x-ray

1.5

Postoperative Protocols

Another equally important tool is to establish postoperative protocols and to adhere to them. Much like the efficiencies and clarity the preoperative planning conference and the surgical booking sheet bring to the operative experience, established postoperative protocols do the same for the recovery and rehabilitation process. We have separated our surgeries at OFAC into six unique groups and discuss the postoperative protocol with the patient during the surgical consent visit (Fig. 1.10). This document is part of the electronic patient chart so anyone in contact with the patient during the postoperative course can review and discuss any questions as to next steps in care. The patient is also given a copy so they are aware of the plan as well. This reduces patient confusion and anxiety as to the postoperative course and makes each office

Fig. 1.7  Case example, preoperative AP CT image

visit more efficient and streamlined. Research and data collection is also improved in a group practice if all providers follow standard postoperative protocols so larger volume collection can be done and comparative studies can be performed.

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Fig. 1.8  Case example, completed surgical request form

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1  Preoperative Considerations, Surgical Planning, and Postoperative Protocols

Fig. 1.9  Case example, recent clinical note indicating surgical plan

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Name: OFAC Surgical Protocols Group 1 (NWB Splint 1 Week, WBAT Boot 3 Weeks, Physical Therapy @ 4-6 weeks PRN) Ankle Scope Debridement*

Cheilectomy*

Ankle Arthrotomy*

Mass Excision

Hardware Removal*

Neuroma Excision

Synovectomy*

Excision Coalition

Tenotomy, Toe Flexor/Extensor Excision Exostosis Topaz PF***

Group 2 (NWB Splint 1 Week, WBAT Boot 4-5 Weeks, Physical Therapy @ 6-8 weeks PRN) Arthrodesis, 1st MTPJ

Bunionette

Hammertoe Correction***

Bunion, Met Osteotomy***

Metatarsal Head Excision

Plantar Plate repair***

Group 3 (NWB Splint 1 Week, NWBC 3 Weeks, WBAT Boot 4 Weeks, Physical Therapy) Ankle OCD Drill/Graft

ORIF Fibula***

1st TMT Lapidus***

ORIF Syndesmosis***

Tarsal Tunnel Release***

TAR**

Peroneal Repair***

Achilles Repair**

Brostrom***

Group 4 (NWB Splint 1 Week, NWBC 3 Weeks, WBC 2 Weeks, WBAT Boot 4 Weeks, PT W/Brace) Chrisman-Snook***

Brostrom Evans***

Isolated ORIF Metatarsal***

Group 5 (NWB Splint 1 Week, NWBC 3 Weeks, NWBC 3 Weeks, WBAT Boot 4 Weeks, PT W/Brace) PTT Repair w/ transfer w/ or w/o LCL, MDCO*** ORIF Bimal/Tibial Osteotomy***

Subtalar Arthrodesis

Lisfranc ORIF/Arthrodesis

TMT and Midfoot Arthrodesis

ORIF Multiple Metatarsals

Group 6 (NWB Splint 1 Week, NWBC 3 Weeks, NWBC 3 Weeks, WBC 3 Weeks, WBAT Boot, Arizona Brace) Ankle Arthrodesis

Pantalar Arthrodesis

TN Arthrodesis

TTC Arthrodesis

Triple Arthrodesis

ORIF Calcaneus

ORIF Talus

Medial Double * PT @ 4 Weeks

** PT @ 6 Weeks

NWB = Non Weight Bearing

NWBC = Non Weight Bearing Cast

WBAT = Weight Bearing as Tolerated

Fig. 1.10  OFAC postoperative protocols

***PT @ 8 Weeks

WBC = Weight Bearing Cast

1  Preoperative Considerations, Surgical Planning, and Postoperative Protocols

In subsequent chapters, you may see other authors refer to this chapter for postoperative protocols for the content they are covering. The protocols we present here are merely a ­suggestion and have come from our practical experience and consensus among the surgeons at OFAC.

References 1. Via M.  The malnutrition of obesity: micronutrient deficiencies that promote diabetes. ISRN Endocrinol. 2012;2012:103472.

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2. Pinzur MS, Stuck RM, Sage R, Hunt N, Rabinovich Z. Syme ankle disarticulation in patients with diabetes. J Bone Joint Surg Am. 2003;85:1667–72. 3. Garber AJ, Moghissi ES, Bransome ED Jr, et  al. American College of Endocrinology position statement on inpatient diabetes and metabolic control. Endocr Pract. 2004;10(1):77–82. 4. Clement S, Braithwite SS, Magee MF, et  al. Management of diabetes and hyperglycemia in hospitals. Diabetes Care. 2004;27(2):553–91. 5. American Diabetes Association. Standards of medical care in diabetes: 2008. Diabetes Care. 2008;31(suppl 1):S12–54. 6. Whalen J, Spelsberg S, Murray P.  Wound breakdown after total ankle arthroplasty. Foot Ankle Int. 2010;31(4):301–5.

2

Hallux Valgus Correction Osteotomies Maria Romano McGann, David S. Buchan, and Christopher F. Hyer

Hallux valgus is one of the most common forefoot disorders that causes pain and dysfunction. The overall prevalence is approximately 30% in females and 13% in males [9]. This is a complex deformity with a variety of treatment options. When evaluating patients for bunion surgery, there are a few radiographic and clinical parameters that are used to determine the surgery. The hallux valgus angle (HVA) is the measurement of the long axis of the 1st metatarsal and proximal phalanx. This is useful to assess the degrees of hallux valgus at the 1st MTP joint and gain insight into how much soft tissue correction or release may be needed to gain correction. The distal metatarsal articular angle (DMAA), also known as the proximal articular set angle (PASA), is the angle between the 1st metatarsal (1st MT) long axis and the base of the distal articular cap of the 1st MT. This represents the angle at which the articular facet of the metatarsal is aiming. In long-standing deformities, adaptive change to the articular surface may place a role in the valgus deviation of the joint and may need to be

M. R. McGann (*) Romano Orthopaedic Center, Oak Park, IL, USA D. S. Buchan · C. F. Hyer Orthopedic Foot & Ankle Center, Worthington, OH, USA

addressed. It is the authors’ opinion that this be reassessed intraoperatively as radiographic appearance of an increased DMMA may not be as evident in the actual cartilage itself. Another useful angle is the intermetatarsal angle (IMA) 1–2 which is the angle between long axis of 1st and 2nd MT. In addition, both clinical and radiographic evaluation for 1st ray hypermobility/ instability as well as painful arthritis of either the 1st MTP or 1st TMT joints is advised. Also, careful consideration should be taken for an increase in the hallux interphalangeus angle (HIA), which is the longitudinal bisection of the long axis of the proximal phalanx of the hallux and the base the distal articular cap of the proximal phalanx. This, in addition to the clinical appearance of the hallux distal to the 1st MTP joint, may indicate need and use for the Akin osteotomy.

2.1

Presentation

Hallux valgus is a progressive triplane foot ­deformity in which the proximal phalanx moves into valgus and the first metatarsal into varus [12]. The toe becomes pronated and dorsiflexed due to the lateral deviation of extensor hallucis longus and flexor creating an adductor moment. Contractures of the adductor hallucis, the lateral capsule, and the lateral head of flexor hallucis longus further exacerbate the deformity. The sesamoids subluxate l­aterally [8, 11, 12]. Each

© Springer Nature Switzerland AG 2019 C. F. Hyer et al. (eds.), Essential Foot and Ankle Surgical Techniques, https://doi.org/10.1007/978-3-030-14778-5_2

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of these deformities needs to be addressed in order to correct the foot and not create secondary deformities [3, 10]. Patients complain of medial prominence and lateral deviation of their great toes with difficulty wearing shoes. There is pain located along the medial eminence as rubbing in shoes occurs and a bursitis develops. Later stages have hammering of their second toes due to overcrowding. Ultimately, with joint malposition, osteoarthritic changes develop leading to joint pain and limitation in range of motion. Below are case examples of different patients and our treatment preference for these patients. Case 1  Modified Reverdin case: The patient is a 60-year-old female with a painful bunion deformity that has progressively worsened over the years. On physical exam, the patient has a hallux valgus deformity with lateral deviation of her great toe. The great toe is manually reducible and the medial column is stable. Radiographically, there is an increased DMAA and a mild to moderately increased hallux ­valgus angle. Case 2  Mau case: The patient is a 50-year-old female presenting to the clinic with painful bunion deformity over several years that has progressively gotten worse. She states pain is 4–5 during the day when she is active and in shoes. At night, her pain can be up to 8/10. She has started to off-­ load her great toe by walking on the outside of her foot. On physical exam, the patient has a hallux valgus deformity with deviation of the great toe laterally. The toe is manually reducible without medial column instability. There is not a significant pronation deformity of the toe. Radiographs demonstrate an increased IMA of approximately 17° and a mild to moderately increased HVA. There is lateralization of the sesamoids and slight hallux interphalangeus deformity noted. Case 3  Scarf case: The patient is a 60-year-old female presenting to the clinic with a 20-year ­history of a painful progressive bunion deformity.

She works on her feet all day and states she has gotten to the point that she cannot live with it any longer. She has tried anti-inflammatories, various types of shoes, and padding, with no relief. On physical exam, she has a hallux valgus deformity with deviation of her great toe laterally. Full motion of the 1st MTP is present. The great toe is manually reducible. There is no medial column instability and minimal pronation deformity of the 1st ray. X-rays demonstrate an intermetatarsal angle (IMA) greater than 12°. Hallux valgus angle (HVA) is moderate to severe. Case 4  1st MTP fusion case: The patient is an 80-year-old female returning to clinic with a severe hallux valgus deformity with hallux DJD. Her toes have gotten worse. She does not care about wearing fashionable wedge shoes. On physical exam, the patient has a hallux valgus deformity that is manually reducible with minimal medial column instability. 1st MTP motion is limited and painful throughout the range of motion. Radiographs demonstrate a hallux valgus deformity with joint space narrowing of the 1st MTP joint and sclerosis. Hammering of her 2nd and 3rd toes is noted.

2.2

Indications

2.2.1 Modified Reverdin Osteotomy A modified Reverdin osteotomy is a biplanar osteotomy performed on patients with hallux valgus and an increased DMAA. This is a medially based closing wedge osteotomy that is performed 1/8 inch proximal to and parallel to the articular surface of the 1st metatarsal to correct DMAA (Fig. 2.1). It is often performed with inferior arm of chevron osteotomy for stability and ease of internal fixation. Originally this was an incomplete cut with the lateral cortex remaining intact; however, we usually complete the cut from medial to lateral to allow lateral translation of the  capital fragment to further reduce the IM deformity.

2  Hallux Valgus Correction Osteotomies

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2.2.2 Mau Osteotomy

the plantar flare of the 1st metatarsal (Fig. 2.2). This is still long enough to provide inherent staA Mau osteotomy is an oblique osteotomy that is bility and allow two screw fixations across the performed at times for moderate to severe osteotomy. increased first IMA. This osteotomy is more staSimilar to a scarf, a Mau allows translation ble than a Reverdin and easy to perform and fix- and rotation of the distal fragment. It provides a ate compared to other proximal osteotomies [6, broad surface for fixation to help primary bone 15, 16]. The osteotomy is directed from dorsal-­ healing. Correction of moderate to severe bunion distal on the 1st metatarsal starting in the distal deformities is able to be made with high union 1/3 and direct plantar and proximal to end in the rates. This also has a low incidence of transfer proximal 1/3 of the 1st metatarsal. We use a mod- metatarsalgia that can be complications of other ified technique and make the osteotomy slightly proximal osteotomies [7]. This should also be more vertical and start it dorsal-distal in the prox- performed in patients with stable 1st TMT and imal 1/3 to ½ of the metatarsal and direct it into intercuneiform joints (Fig. 2.3).

Fig. 2.1  Mau osteotomy

a

b

Fig. 2.2 (a–d) Mau: Pre- and post-op x-rays for Mau osteotomy

M. R. McGann et al.

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c

d

Fig. 2.2 (continued)

a

d

b

c

e

Fig. 2.3 (a–e) Mau and Akin osteotomy: Pre- and post-op x-rays from Mau and Akin osteotomy

2.2.3 Scarf Osteotomy Scarf osteotomies can be performed for a wide range of bunion patients. This is the workhorse

osteotomy performed by the senior authors to correct bunion deformities. The greater the deformity, the longer the transverse arm is required. If the patient has a moderately to severely increased

2  Hallux Valgus Correction Osteotomies

HVA and IM 1–2, this may be supplemented with an Akin procedure for additional correction. Patients are examined for hypermobility between their first and second rays. Stable first tarsometatarsal and intercuneiform joints are required for success with this osteotomy and maintained correction. Similar to first MTP fusions, satisfaction scores are high with Scarf osteotomies [5]. Not only are patients more likely to return to more complex athletic activity such as gymnastics, cycling, and skiing with this type of osteotomy compared to 1st MTP fusion patients, but they also functionally have less difficulty doing most athletic activities [5]. If the first ray needs to be shortened in its correction, this may also be done through this osteotomy by angling the proximal and distal arms of the “Z” toward the base of the 5th metatarsal.

2.2.4 First Metatarsophalangeal Fusion Patients who benefit from a first metatarsophalangeal (MTP) fusion have a significant arthritic component to their bunion deformity or have severe deformities that have high chance of recurrence. Radiographically, there may be joint space narrowing, flattening of the joint, and dorsal

a

Fig. 2.4 (a–d) MTP fusion case: Pre- and post-op x-rays

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spurring in addition to an obvious HAV deformity (Fig. 2.4). Clinically, patients have painful, first MTP joint with limited range of motion. Functionally, patients report a significant improvement in their activities of daily living [4]. The vast majority of patients are limited for wearing comfort shoes after the procedure, and 55% were limited in their high heel height. The majority of patients were able to return back to their recreational activities such as running, golf, hiking, and tennis [1, 4].

2.2.5 Akin Osteotomy The Akin osteotomy is primarily an adjunct procedure to “dial-in” final corrections of the bunion deformity, after the proximal osteotomy is made to correct the intermetatarsal angle, ­ DMAA/ PASA, and hallux valgus angles [2]. This medial wedge, closing osteotomy is performed at the base of the proximal phalanx. The lateral cortex is used as a hinge on which to close the osteotomy [13]. Corrections may be made in the coronal and sagittal planes to allow frontal plane corrections. Fixation may be done with either a single staple or compression screw [2]. Patients requiring Akins often have larger preoperative HVAs or increased HIA deformity. There are two

b

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c

d

Fig. 2.4 (continued)

common techniques to perform the Akin: (1) a transverse osteotomy medial to lateral with removal of a small medially based wedge to achieve correction – this technique is usually fixated with staple fixation either medially or dorsally – and (2) an oblique medially based closing wedge osteotomy directed from distal medial to proximal lateral. This osteotomy lends itself well to an oblique lag screw fixation from proximal medial to distal lateral perpendicular to the osteotomy. Either technique is acceptable, but the authors find the long oblique osteotomy more stable and easier to achieve large corrections when needed.

either through the medial incision at the first MTP or through a separate dorsal incision in the first webspace. The first webspace incision is preferred in cases when significant rotation of the sesamoid into the interspace or along the lateral 1st metatarsal head is seen on AP radiographs. Care is taken to avoid the deep peroneal nerve during dissection and to only release the lateral sesamoid suspensory ligament. In most cases, the adductor hallucis tendon is not released from the lateral phalangeal base in an effort to avoid postoperative hallux varus deformity.

2.2.6 Distal Soft Tissue Procedure

There are four standard x-rays that are obtained on all of our bunion patients. These are an AP, lateral, and oblique weight-bearing views of the affected foot along with a sesamoid view. These set of x-rays allow the surgeon to assess the extent of the deformity and arthritis present in the joints. The sesamoid view assesses the extent of the rotational component to the overall deformity. These are all necessary for preoperative planning.

Distal soft tissue procedures can be performed in solitary for a very mild increase in hallux valgus angle. The majority of the time, this is done as an adjunct procedure to the osteotomies to help correct the deformity and to help reduce the sesamoids. It is typically performed in a juvenile hallux valgus or when the sesamoid position is 4 or more on an AP radiograph. It can be completed

2.3

Imaging

2  Hallux Valgus Correction Osteotomies

2.4

OR Setup

Thigh tourniquet Weitlaner self-retaining retractor 10 × 15 oscillating saw on TPS Baby Hohmann ×2 Small rongeur Seeburger ribbon retractor McGlamry elevator 2.5 mm and 3.0 mm headless compression screws for osteotomy sites Mini-fluoro Place pt at foot of the bed Small bump under ankle Hardware selection • 2.5 headless screw for Akin × 1 • 3.0 headless screw × 2 for Scarf or Mau • 4.0 headless screw for MTP fusion with dorsal locking compression plate

2.5

Operative Technique

2.5.1 Reverdin 1. Medial capsulotomy using a standard medial approach. 2. Perform transverse osteotomy approximately 1 cm proximal and parallel to the articular surface of the metatarsal head. 3. Feather lateral cortex. May complete cut to lateral cortex if translation of the metatarsal head is required. 4. Make distal cut at the angle required to correct the DMAA, typically parallel to the articular surface of the 1st metatarsal head. 5. It is also performed with inferior arm of chevron osteotomy for stability and ease of internal fixation. 6. Confirm per fluoro that head rotates around and reduced DMAA after removal of medial wedge and completion of inferior arm of osteotomy. Additional “feathering” can be performed medially along the transverse osteotomy to allow further closure of the DMAA.

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2.5.2 Mau Osteotomy 1. Medial capsulotomy performed using a standard medial approach which can be split into two segments, one for medial 1st MTP ­exposure and a second one from proximal 1/3 metatarsal and 1st TMT exposure. 2. Access the proximal aspect of 1st MT through 3 cm dorsal medial incision. 3. Identify 1st TMT joint and make oblique osteotomy 1 cm distal to joint. The joint does not need to be opened or released. 4. Oblique osteotomy from dorsal-distal diaphysis-­ metaphysis junction to plantar-­ proximal metaphysis as parallel to the weight-­ bearing surface as possible but being mindful to terminate the osteotomy in the plantar flair of the metatarsal and not extend into the 1st TMT joint. 5. A “biplanar wedge” can be removed from the osteotomy to allow front plane rotation and correction of the first metatarsal if needed. 6. Rotate the distal fragment to reduce the IMA less than 9°. This is accomplished by using a baby human retractor on the proximal lateral base of the first metatarsal and driving this medially while at the same time using your hand on the medial first metatarsal head and driving the distal fragment laterally. 7. This osteotomy can be both translated from medial to lateral as well as rotated on the transverse plane (like the blades of a pair of scissors) to further correct IM angle as well as dial in DMAA deformity as needed. 8. A bone clamp can be used to temporarily reduce the osteotomy and place a guide wire from the proximal dorsal to distal plantar, perpendicular to the osteotomy. 9. Drill and place 3.0  mm cannulated headless screws × 2.

2.5.3 Scarf Osteotomy 1. A medial incision is made along the first MTP joint (Fig. 2.5).

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Fig. 2.5  A medial-based incision over the 1st MTP joint and extending proximally along the first metatarsal for the Scarf osteotomy

2. With care to protect the dorsal medial cutaneous nerve, elevate the plane between skin and capsule. 3. Next a medial longitudinal capsulotomy is made in line with the skin. 4. Subperiosteally elevate the capsule off the metatarsal head and shaft. 5. Release along the plantar surface of the metatarsal. 6. Release lateral structures with knife from medial side. Passively correct the great toe to at least 45°. 7. Insert a guide pin in metatarsal (MT) head for resection guide. This sets center of axis as well as protecting from the excursion of blade. Use the pin that will be used for cannulated headless screw which will be placed for fixation (Fig. 2.6). 8. Make dorsal cut distally with oscillating saw aimed at 5th MT head to help shorten shaft with shift. Increase angle, if more shortening is desired. Decrease the angle to make the cut more transverse if little to no shortening is necessary. 9. Midshaft longitudinal cut. A shorter cut is used for less correction. A longer cut down the metatarsal shaft is required for a larger correction.

Fig. 2.6  Insertion of K-wire into the metatarsal head as a cut guide for the Scarf osteotomy

1 0. Proximal plantar cut parallel to dorsal cut. 11. Cut small wedge of bone proximally to the most proximal cut to allow for rotation of the MT and correction of the DMAA/PASA. 12. A shift of up to 50% of width of MT can be made. Can use a towel clamp to help create shift (Fig. 2.7). 13. Secure the osteotomy with two headless compression screws (Fig. 2.8). 14. Take a fluoro image of the correction that is made at this point. Carefully assess the reduction of the sesamoids as well. 15. Use towel clamp medially to assess if capsule closure will reduce toe and sesamoids or if an Akin and DSTP are required. If there’s any question or it seems that the capsular repair must be very tight to keep everything in alignment, have a low threshold to perform one or both of these adjunct procedures. 16. Medial capsular imbrication performed with pants-over-vest repair. Remove the redundant tissue medially. Think of the sesamoids

2  Hallux Valgus Correction Osteotomies

23

Fig. 2.7  Towel clips may be used to aid in the shift of the osteotomy to help reduce the IM and HV angles

Fig. 2.9  Sesamoid view

2.5.4 Akin Osteotomy

Fig. 2.8  Guide wires inserted into the metatarsal head and vertically in metatarsal shaft. 3.0 mm headless compression screws are then placed after wire position is confirmed and adequate reduction achieved

as a sling that we are stabilizing in the frontal plane to keep sesamoids reduced plantarly. Think of sesamoid axial view x-rays (Fig. 2.9).

1. Perform after proximal osteotomy and soft ­tissue release are completed. 2. Insert guide wire from medial mid-diaphysis angling toward lateral flare of proximal phalanx. This is used as a cut guide. 3. Confirm proper trajectory with c-arm. 4. Use oscillating saw to take a small wedge of bone. Make sure to keep axis of hinge vertical AND perpendicular to the weight-bearing surface. Remember, as the osteotomy closes, it will follow this hinge. If the hinge is angled, it may cause unwanted DF as it closes. 5. Feather lateral cortex. Take care to go through dorsal and plantar cortex along length of the cut. Use baby Hohmann to protect dorsal and plantar structures especially EHL and FDL.

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6. Use the same cut-guide pin to fixate osteotomy site. 7. Insert 2.5 mm headless screw. Usually, drilling only the medial cortex is necessary.

2.5.5 Distal Soft Tissue Procedure 1. May attempt to release lateral structures through medial incision if possible to get enough release. 2. Traditionally a separate 1st webspace incision is made to provide more of a release. 3. Use 15-blade to cut skin. Then use the blunt end of the knife handle to bluntly dissect down to lateral structures. 4. Release adductor hallucis insertion, including attachment to fibular sesamoid. 5. Release transverse intermetatarsal ligament. 6. Pie crust lateral capsule with multiple vertical cuts through the cortex. 7. If done through medial approach, carefully use blade to release intermetatarsal ligament and allow sesamoid to sling over medially. Then, hug the bone on the metatarsal to release adductor insertion. 8. Apply varus stress. If less than 45° of correction achieved in MTP, further releases may need to be made.

2.6

Post-op Protocol

A standard sterile address is applied consisting of adaptic, 4  ×  4s, abdominal pads, and webril loosely applied circumferentially. A Bulky-Jones posterior mold splint is applied by rolling the cotton roll out and placing 10 slabs of 4  ×  30cm plaster splint over the top.

Pearls

Potential Complications • Recurrent hallux valgus, especially with adjunct akin [14]. • Hallux varus is a strong possibility if the following triad occurs: removal of the fibular sesamoid, staking the head (or removal too much of the medial eminence), and creating a negative intermetatarsal angle. Two out of three of these are required to develop hallux varus. • Wound complications.

References 1. Brodsky JW, Passmore RN, Pollo FE, Shabat S. Functional outcome of arthrodesis of the first metatarsophalangeal joint using parallel screw fixation. Foot Ankle Int. 2005;26(2):140–6. 2. Bussewitz BW, Levar T, Hyer CF. Modern techniques in hallux abducto valgus surgery. Clin Podiatr Med Surg. 2011;28(2):287–303. 3. Dayton P, Feilmeier M, Kauwe M, Hirschi J.  Relationship of frontal plane rotation of first metatarsal to proximal articular set angle and hallux alignment in patients undergoing tarsometatarsal arthrodesis for hallux abducto valgus: a case series and critical review of the literature. J Foot Ankle Surg. 2013;52:348–54. 4. DeSandis B, Pino A, Levine DS, Roberts M, Deland J, O’Malley M, Elliott A. Functional outcomes following first metatarsophalangeal arthrodesis. Foot Ankle Int. 2016;37(7):715–21. 5. Desmarchelier R, Bessea JL, Fessya MH, The French Association of Foot Surgery (AFCP). Scarf osteotomy versus metatarsophalangeal arthrodesis in forefoot first ray disorders: comparison of functional outcomes. Orthop Traumatol Surg Res. 2012;98(6, Supplement):S77–84. 6. Glover JP, Hyer CF, Berlet GC, Lee TH. Early results of the Mau osteotomy for correction of m ­ oderate

2  Hallux Valgus Correction Osteotomies to severe hallux valgus: a review of 24 cases. J Foot Ankle Surg. 2008;47(3):237–42. https://doi. org/10.1053/j.jfas.2008.02.004. Epub 2008 Apr 2. 7. Hyer CF, Glover JP, Berlet GC, Philbin TM, Lee TH.  A comparison of the crescentic and mau osteotomies for correction of Hallux Valgus. J Foot Ankle Surg. 2008;47(2):103–11. 8. Kim Y, Kim JS, Young KW, Naraghi R, Cho HK, Lee SY. A new measure of tibial sesamoid position in hallux valgus in relation to the coronal rotation of the first metatarsal in CT scans. AOFAS. 2015;36(8):944–52. 9. Nix S, Smith M, Nix BV, et al. Prevalence of hallux valgus in the general population: a systematic review and meta analysis. J Foot Ankle Res. 2010;3:21. 10. Paley D, Herzenber JE, editors. Principles of deformity correction. Berlin: Springer; 2005. 11. Perera AM, Mason L, Stephens MM.  The Pathogenesis of Hallux Valgus. J Bone Joint Surg-Am. 1994;93(17):1650–61.

25 12. Robinson AH, Limbers JP.  Modern concepts in the treatment of hallux valgus. J Bone Joint Surg. 2005;87(8):1038–45. 13. Sabo D. Correction osteotomy of the first phalanx of the great toe (Akin osteotomy). Int Surg. 2007;2:66–9. 14. Shibuya N, Thorud JC, Martin LR, Plemmons BS, Jupiter DC.  Evaluation of hallux valgus correction with versus without Akin proximal phalanx osteotomy. J Foot Ankle Surg. 2016;55(5):910–4. 15. Trnka HJ, Parks BG, Ivanic G, Chu IT, Easley ME, Schon LC, Myerson MS.  Six first metatarsal shaft osteotomies: mechanical and immobilization comparisons. Clin Orthop Relat Res. 2000;381:256–65. 16. Vora AM, Myerson MS.  First metatarsal oste otomy nonunion and malunion. Foot Ankle Clin. 2005;10(1):35–54.

3

Lapidus HAV Correction W. Bret Smith, B. Collier Watson, and Christopher W. Reb

When Paul Lapidus described his technique for arthrodesis of the 1st TMT (tarsometatarsal) joint in 1934, he was building on the work of others (most notably Albrecht and Truslow) [1, 2]. Lapidus felt that the basis of the hallux abducto valgus deformity was centered at the TMT joint and was related to hypermobility [3–5]. The recommendations by Dr. Lapidus at the time were to take down and prepare the 1st TMT joint as well as the interspace between the 1st and 2nd MT (metatarsal). Correction was to address the transverse and sagittal deformities and fixate the joint in the new position. Obviously, over the course of many decades, there have been numerous modifications and comments on the procedure based at the 1st TMT joint. Later dissertations on the procedure began to focus on fixation of the arthrodesis. Initially this was in the form of screw osteosynthesis [6,  7]. More recently with the addition of plate

W. B. Smith (*) Foot and Ankle Division Palmetto Health-USC Orthopedic Center, Palmetto Health, Department of Orthopedic Surgery, Lexington, SC, USA B. C. Watson The Hughston Clinic, Columbus, GA, USA C. W. Reb University of Florida, Department of Orthopedics, Division of Foot and Ankle Surgery, Gainesvilles, FL, USA

fixation, specifically locked constructs have been evaluated [8–11]. With a bunion deformity, the fundamental problem is deviation of the hallux at the ­metatarsophalangeal joint (MTP) and deviation of the first metatarsal at the tarsometatarsal joint (TMT). Traditionally we prioritized anterior-posterior (AP) radiograph findings such as the intermetatarsal angle (IMA), hallux valgus angle (HVA), tibial sesamoid position (TSP), and joint surface angle known both as distal metatarsal articular angle (DMAA) and proximal articular set angle (PASA). It is vital to recognize that since the AP radiograph is a two-dimensional representation of the true three-dimensional anatomy, deviation in the other planes, such as frontal plane rotation of the first metatarsal, can substantially change all visible cues on the AP radiograph. Pronation of the first metatarsal changes the appearance of the DMAA, TSP, medial eminence and the shape of the lateral metatarsal head. To identify and characterize the contribution of the frontal and sagittal plane deviations to the radiographic cues on the AP radiograph, we must look at different landmarks and anatomy on axial and lateral radiographic views. In addition to recognizing the individual planar components, we must also focus our corrective procedure on the apex of the deformity or the anatomic CORA (Paley). The apex of the metatarsal component of the deformity in a bunion has been described by many surgeons and researchers to be

© Springer Nature Switzerland AG 2019 C. F. Hyer et al. (eds.), Essential Foot and Ankle Surgical Techniques, https://doi.org/10.1007/978-3-030-14778-5_3

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not in the metatarsal but at the TMT [12–15]. The triplane tarsometatarsal corrective arthrodesis specifically uses all three planes to both evaluate and correct the deformity. Using a triplane framework for evaluation and procedure selection and focusing on the apex of the deformity will help in a more anatomic and complete correction.

3.1

a

Surgical Management

3.1.1 Positioning and Equipment (a) Place patient in supine position on a radiolucent table. (b) Well-padded upper thigh tourniquet to operative leg. (c) Bump placed under ipsilateral hip so that toes are pointed to the ceiling. (d) Surgical assistant and instrument table are on side of OR table opposite to the surgical foot. (e) We prefer use of mini C-arm and position it on the same side as operative foot. (f) Surgeon sits at either foot of bed or on same side of operative foot. (g) Preoperative xrays should be viewable in the operating room. (Fig. 3.1a, b)

b

3.1.2 Approach (a) Using a 15-blade knife, a medial longitudinal incision is made along the 1st metatarsophalangeal joint (MTP) (Fig. 3.2). (b) Identify the dorsomedial branch of the superficial peroneal nerve as well as the vessels coursing along the medial aspect of the 1st metatarsal. Using the knife or tenotomy scissors, gently tease the neurovascular bundle off of the underlying fascia, and retract the bundle dorsally.

3.1.3 D  istal Soft Tissue Procedure (DSTP) (a) The medial capsule around the 1st MTP joint can be clearly visualized at this point (Fig. 3.3). Starting at the base of the proxi-

Fig. 3.1 (a, b) AP and lateral radiographs demonstrating hallux valgus deformity

mal phalanx, make a medial longitudinal incision through the capsule and in line with the incision toward the distal aspect of the 1st metatarsal. There is typically redundant capsular tissue present. Excision and imbrication of this redundant tissue will be discussed later in the chapter. (b) Using the knife, sharply release the capsule from around the dorsal and plantar aspects of the joint particularly beneath the 1st metatarsal head (Fig. 3.4). (c) To prevent having to make a separate lateral incision in the 1st webspace, place a small “baby” Gelpi retractor underneath the 1st

3  Lapidus HAV Correction

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Fig. 3.2  A sharp knife is used to make a longitudinal incision along the medial aspect of the 1st MTP joint

Fig. 3.4  Medial capsule is released dorsally and plantarly around the 1st metatarsal head

Fig. 3.3  The medial capsule at the 1st MTP joint is visualized

metatarsal head, and distract the plantar soft tissues away from the metatarsal. This increases the view of the position of sesamoids. We can typically see the lateral metatarso-­sesamoidal ligament at this point (Fig. 3.5). (d) By placing the knife under the metatarsal head, it can be used to release the lateral metatarso-sesamoidal ligament. Apply a 45° varus stress of the 1st MTP joint to relax the contracted lateral capsular tissues. (e) A Freer elevator can be used to palpate the sesamoids, and at this point, they should be freely mobile. • If we are unable to release the lateral metatarso-sesamoidal ligament through the medial incision, then we make a separate dorsal incision at the 1st webspace. • Carefully, dissect down to the lateral 1st MTP joint capsule.

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a

b

Fig. 3.5 Small Gelpi retractor is placed underneath the1st metatarsal head to distract the sesamoids. This allows visualization of the lateral metatarso-sesamoidal ligament for release

• Fenestrate the capsule with a 15-blade knife. • Apply a 45° varus stress to the 1st MTP joint to release the contracted tissue, which allows for the sesamoids to mobilize. (f) To confirm that we have adequate release of the sesamoids, a towel clip is placed around the medial capsular tissue, and we tighten down the medial capsule with the towel clip (Fig. 3.6a, b). (g) An AP fluoroscopic image is obtained to assess whether or not the sesamoids have reduced beneath the metatarsal head.

Fig. 3.6 (a, b) A towel clip is placed around the medial capsule to simulate imbrication of the medial capsule. An AP fluoroscopic image confirms that the sesamoids are reduced underneath the 1st metatarsal head

• If the sesamoids are not reduced beneath the metatarsal head, release more of the lateral capsule, and then reassess sesamoid reduction again with the same technique mentioned above. (h) At the end of the case, we turn our attention back to the DSTP to imbricate the capsule, which is discussed later in this chapter.

3  Lapidus HAV Correction

3.1.4 P  artial Excision 1st Metatarsal Head (Silver Osteotomy) (a) Using the same medial incision, and after the medial capsule has been released from the 1st MTP joint, use an oscillating saw to remove the medial eminence. This results in a smooth medial border along the 1st metatarsal head (Fig. 3.7). • Be careful not to excise part of the articular cartilage.

3.1.5 Calcaneus Autograft Harvest (a) A 1–2 cm oblique incision is made over the lateral aspect of the calcaneal tuberosity. (b) Blunt dissection is carried down to the lateral wall of the calcaneus using a Key periosteal elevator.

Fig. 3.7  Partial excision 1st metatarsal is completed using an oscillating saw to remove the large prominent medial eminence

31

• Keep in mind that the sural nerve is within the anterior skin flap of the incision. (c) We use a 5 mm bone graft harvester to obtain 5–8 cc of bone graft from the calcaneus. The graft is placed in a specimen cup for later use at the Lapidus fusion site. (d) The wound is thoroughly irrigated to remove bone debris from the subcutaneous tissues. (e) Skin is closed with 3-0 Nylon suture.

3.1.6 1st Tarsometatarsal Joint Fusion (Lapidus) (a) After completion of the distal soft tissue procedure and partial excision 1st metatarsal, we then proceed with the Lapidus portion of the case. (b) To confirm exact location of the joint, we mark out the joint using a Freer elevator and an AP fluoroscopic x-ray. (c) Using a 15-blade knife, a dorsomedial incision is centered over the 1st TMT joint. (d) A Bovie is used for hemostasis within the subcutaneous tissues. (e) Look for the medial branch of the superficial peroneal nerve within the incision, and retract it either medially or laterally. (f) With the nerve protected, incise the extensor hallucis longus (EHL) tendon sheath, and retract the EHL tendon laterally. (g) Now incise the 1st TMT joint capsule in line with the incision. Carefully reflect the capsular tissue medially and laterally around the joint. • Be careful with the lateral dissection as the dorsalis pedis artery and anterior tibial nerve dive between the base of the 1st and 2nd metatarsals. • Assuming we have good exposure of the joint, we try to leave a cuff of the medial capsule attached to the joint to contain our autograft at the fusion site. A Hintermann retractor is placed over the dorsal aspect of the joint and fixed to the medial cuneiform and base of 1st metatarsal with pins (Fig. 3.8). The Hintermann is used for distraction

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Fig. 3.8  After dorsomedial approach to the 1st TMT joint, a Hintermann retractor is used to distract the 1st TMT joint to prep the joint for fusion

Fig. 3.9  The 1st TMT joint cartilage is removed. A series of perforations is made at the joint surface with a small solid drill bit followed by fish scaling the area with an osteotome

to increase the access to the 1st TMT articular surface.

(k) A solid drill bit is used to make a series of perforations on each side of the joint ­followed by “fish scaling” the surfaces with an osteotome. We also drill the medial base of the 2nd metatarsal to get a spot-weld fusion to lessen the risk of hallux valgus recurrence (Fig. 3.10). (l) The calcaneus autograft is now packed into the fusion site. (m) The Hintermann retractor is removed and the 1st TMT joint is reduced. (n) Next, the 1–2 intermetatarsal angle is reduced using a large bone reduction clamp.

(h) If more distraction is needed to gain exposure to the joint, a ¼ inch osteotome can be used to divide the plantar ligament/capsule at the inferior aspect of the 1st TMT joint. (i) With the joint now fully exposed, the cartilage is removed with curettes and osteotomes (Fig. 3.9). (j) The joint is thoroughly irrigated with normal saline to remove the cartilage debris.

3  Lapidus HAV Correction

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a

b

Fig. 3.10  The medial base of the 2nd metatarsal is drilled with a solid drill bit to get a “spot-weld” fusion

• A small, stab incision is made of the lateral aspect of the 2nd metatarsal neck. • The large bone reduction clamp is then placed around the 2nd metatarsal neck and the medial eminence of the 1st metatarsal (Fig. 3.11a). • The 1st MTP joint is maximally dorsiflexed to recreate the windlass ­ mechanism. • The large reduction clamp is then closed down tightly to reduce the 1–2 intermetatarsal angle. Reduction is confirmed with AP fluoroscopic x-ray (Fig. 3.11b).

Fig. 3.11 (a, b) A large bone reduction clamp is placed around the 2nd metatarsal neck and medial eminence of the 1st metatarsal head to reduce the 1–2 intermetatarsal angle. Reduction and alignment is confirmed with a fluoroscopic AP image

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a

b

Fig. 3.12 (a, b) A guidewire is placed obliquely from the base of the 1st metatarsal to the middle cuneiform. Placement of the guidewire is confirmed with fluoroscopy

–– Our goal is to get the 1st metatarsal parallel with the 2nd metatarsal. –– Assess for sesamoid reduction underneath the 1st metatarsal head. • Next, place a guidewire for a 4.0 mm partially threaded cannulated screw from the medial base of the 1st metatarsal and aim for the center aspect of the middle cuneiform. Confirm guidewire placement with AP, oblique, and  lateral fluoroscopic images (Fig. 3.12a, b). • Measure screw length and drill the over the guidewire through the 1st metatarsal base only, and then place the a­ ppropriately measured 4.0  mm partially threaded

c­annulated screw to get excellent compression and fixation across the 1st TMT joint (Fig. 3.13). –– Confirm screw length and placement with AP and oblique fluoroscopic views. • Next, a Lapidus fusion plate is centered over the dorsomedial aspect of the 1st TMT joint. –– Confirm plate position with fluoroscopic images. • Fixate the plate to the medial cuneiform with locking screws. –– Confirm that the plate position, screw length, and hallux valgus correction

3  Lapidus HAV Correction

35

is appropriate with AP, oblique, and  lateral fluoroscopic images (Fig. 3.14a, b). • The wound is irrigated with normal saline. 2-0 Vicryl is used to close the subcutaneous tissues, and 3-0 Nylon horizontal mattress stitches are used to close the skin. (o) Attention is then turned back to the medial incision along the 1st MTP joint to complete the distal soft tissue procedure. • Redundant medial capsular tissue is excised. • 0-Vicryl suture is used to imbricate the medial capsular tissue using a pants-­ over-­vest stitch. Start each stitch on the dorsal side of the capsule (Fig. 3.15). We recommend closing the capsule from proximal to distal. • The subcutaneous tissue is then closed with 2-0 Vicryl followed by skin closure with 3-0 Nylon horizontal mattress stitch.

Fig. 3.13  The appropriately measured 4.0 mm partially cannulated screw is placed over the guidewire for compression

a

b

Fig. 3.14 (a, b) Confirm plate position, screw length, and hallux valgus correction with fluoroscopic images

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6–8 weeks based on patient comfort and soft tissue edema. • Routine imaging studies are completed at week 5 and week 8 postoperatively. • Patients are encouraged to transition to accommodative soft-sided shoewear at approximately 6–8 weeks if no issues are noted with healing. • Return to fitness walking activities is allowed at the 3-month mark and unrestricted running sports allowed after 4–6  months postoperatively.

Callouts/Pearls

Fig. 3.15  0-Vicryl suture is used to imbricate the medial capsule at the 1st MTP joint using a pants-over-vest technique. The stitch is begun on the dorsal side of the capsule with the sutures being tied from proximal to distal

3.2

Postoperative Protocol

• The patient is placed into a sterile nonadherent dressing with a soft compressive bulky dressing overtop. Based on preference a posterior splint of postoperative shoe can be utilized. • The patient is instructed to be non-weight-­ bearing until the peripheral block has resolved. Ice and elevation are encouraged for the first several weeks after surgery. • After the patient has sensation in the operative limb, they may do protected weight-bearing with assistive devices in the postoperative period. • Sutures are removed at 10–14  days postoperatively. • Protected weight-bearing in a low CAM boot our postoperative shoe is encouraged for

• It is recommended to get weight-­bearing sesamoid axial radiographs preoperatively along with the standard three view foot films to allow for assessment of frontal plane rotation. • During correction of the HAV deformity, if instability at the intercuneiform region is identified, consider arthrodesis of the medial to middle cuneiform. • Activating the windlass mechanism during reduction and fixation can significantly assist in stabilizing the area during the placement of the implants. • Several commercial systems have recently become available that assist in triplanar reduction of the bunion deformity and may be helpful with correction of the HAV deformity.

References 1. Albrecht GH. The pathology and treatment of hallux valgus (in Russian). Russk Vrach. 1991;10:14–9. 2. Truslow W.  Metatarsus primus varus or hallux valgus? J Bone Joint Surg. 1925;7:98. 3. Lapidus P.  Operative correction of the metatarsus varus primus in hallux valgus. Surg Gynecol Obstet. 1934;58:183–91. 4. Lapidus PW.  A quarter of a century of experience with the operative correction of the metatarsus varus primus in hallux valgus. Bull Hosp Joint Dis. 1956;17:404–21.

3  Lapidus HAV Correction 5. Lapidus PW. The author’s bunion operation from 1931 to 1959. Clin Orthop Relat Res. 1960;16:119–35. 6. Sangeorzan BJ, Hansen ST. Modified Lapidus procedure for hallux valgus. Foot Ankle. 1989;9:262–6. 7. Myerson M, Allon S, McGarvey W. Metatarso­ cuneiform arthrodesis for management of hallux valgus and metatarsus primus varus. Foot Ankle. 1992;13(3):107–15. 8. Cottom JM, Vora AM.  Fixation of Lapidus arthrodesis with a plantar interfragmentary screw and medial locking plate: a report of 88 cases. J Foot Ankle Surg. 2013;52:465–9. 9. Klos K, Gueorguiev B, Mückley T. Stability of medial locking plate and compression screw versus two crossed screws for Lapidus arthrodesis. Foot Ankle Int. 2010;31(2):158–63. 10. Klos K, Simons P, Hajduk A, Hoffmeier KL. Plantar versus dorsomedial locked plating for Lapidus arthrodesis: a biomechanical comparison. Foot Ankle Int. 2011;32(11):1081–5. 11. Scranton PE, Coetzee JC, Carreira D.  Arthrodesis of the first metatarsocuneiform joint: a ­comparative

37 study of fixation methods. Foot Ankle Int. 2009;30(4):341–5. 12. Dayton P, Feilmeier M, Kauwe M, Hirschi J. Relationship of frontal plane rotation of first metatarsal to proximal articular set angle and hallux alignment in patients undergoing tarsometatarsal arthrodesis for hallux abducto valgus: a case series and critical review of the literature. J Foot Ankle Surg. 2013;52(3):348–54. 13. Okuda R, Kinoshita M, Yasuda T, Jotoku T, Kitano N, Shima H.  Postoperative incomplete reduction of the sesamoids as a risk factor for recurrence of hallux valgus. JBJS-Am. 2009;91(7): 637–1645. 14. Mortier J-P, Bernard J-L, Maestro M. Axial rotation of the first metatarsal head in a normal population and hallux valgus patients. Orthop Traumatol Surg Res. 2012;98(6):677–83. 15. DiDomenico LA, Fahim R, Riollandini J, Thomas ZM. Correction of Frontal Plane Rotation of Sesamoid Apparatus During the Lapidus Procedure: a novel approach. J Foot Ankle Surg. 2014;53(2):248-51.

4

Hallux Interphalangeal Joint Arthrodesis and Jones Tendon Transfer Jeffrey S. Weber

4.1

Patient History and Findings

high-impact athletic activities such as competitive dancing, running, and soccer may also prePathology of the hallux interphalangeal joint dispose a patient to degenerative changes within (HIPJ) may stem from a number of disorders. the HIPJ. Neurological disease, such as Charcot-Marie-­ The combination of HIPJ arthrodesis with Tooth, can cause claw toe deformity that becomes transfer of the extensor hallucis longus into the progressively rigid over time. Rigid deformity is 1st metatarsal neck, also known as the Jones tenno longer amenable to soft tissue balancing pro- don transfer, is a predictable procedure with a cedures in later stages of the disease and will relatively small learning curve that serves to allelikely require arthrodesis of the HIPJ. Reducible viate pain, prevent ulceration, and restore the deformity in the presence of a progressive neuro- alignment of the distal first ray. logical disease is also not amenable to soft tissue balancing procedures due to the high likelihood of deformity recurrence. Patients will present 4.2 Clinical Case Example with pain in the hallux and sometimes ulceration at the tip of the hallux from increased pressure A 47-year-old poorly controlled Type II diabetic when weight-bearing or rubbing in shoe gear. As female presents with worsening plantar ulceration the claw toe deformity worsens, a hallux malleus underlying her 1st metatarsophalangeal joint. She deformity may occur in which the extensor hal- has been treated in the wound care center with lucis longus (EHL) tendon contracts. This causes various forms of offloading including total cona retrograde force at the first metatarsophalangeal tact casts as well as various wound care products. joint (MTPJ) in which the first metatarsal She is morbidly obese and unable to maintain becomes plantarflexed which may eventually complete non-weight-bearing to the affected limb. lead to ulceration under the metatarsal head. Clinically, she has a hallux malleus contracture, Trauma is another cause of pain and deformity ankle equinus, and a flexible forefoot valgus. of the HIPJ.  Intraarticular fractures will predis- Vascular status was within normal limits. Her propose a patient to arthritic changes, joint instabil- tective sensation was absent. MRI has been negaity, and deformity. Subtle, repetitive trauma from tive for osteomyelitis. After wound debridement with cultures and an appropriate course of antibiotics, she was taken for definitive surgical correcJ. S. Weber (*) tion of the deformity to off-load this 1st MTPJ Birch Tree Foot and Ankle Specialists, which involved a hallux IPJ fusion with EHL Traverse City, MI, USA © Springer Nature Switzerland AG 2019 C. F. Hyer et al. (eds.), Essential Foot and Ankle Surgical Techniques, https://doi.org/10.1007/978-3-030-14778-5_4

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a

of hindfoot deformity that might also require simultaneous correction.

4.4

Surgical Management

4.4.1 Preoperative Planning

b

Fig. 4.1 (a, b) AP and lateral postoperative radiographs after hallux IPJ fusion, EHL tendon transfer, peroneal and tendoachilles lengthening in a diabetic patient with a neuropathic sub-first MTPJ ulceration

t­endon transfer to the first metatarsal, a peroneus longus lengthening, and Achilles tendon lengthening. She was kept in a total contact cast for 4 weeks postoperatively and eventually transitioned into an extra-depth diabetic shoe. She has remained ulcer free at 8 months postop (Fig. 4.1a, b).

4.3

Imaging and Diagnostic Studies

Routine imaging for hallux IPJ pain and deformity includes three weight-bearing radiographic views (AP, lateral, and medial oblique) to assess the degree of deformity and level of arthrosis. Other deformities, overall bone quality, and cystic changes that may require grafting are assessed simultaneously. A calcaneal axial view may also be helpful in the presence

A thorough history is obtained from the patient well in advance of the surgical procedure to be performed. The assessment of any medical comorbidities must be well-documented and understood in order to optimize the patient for surgery. Diabetes mellitus (DM), peripheral arterial disease (PAD), vitamin D deficiency, kidney disease, rheumatoid and psoriatic arthritis, neurological disease, and tobacco usage are all factors that may prove detrimental to having a successful outcome. Preoperative lab values are routinely performed to assess a patient’s general state of health. Typical lab values include a basic metabolic panel and a complete blood count. At times, the author will perform a comprehensive ­metabolic panel in any patient who is suspected to be malnourished. Vitamin D levels are obtained for surgical patients with a history of vitamin D deficiency, previous stress fracture, or known history or suspicion of osteoporosis. Hemoglobin A1C values are obtained on all diabetic patients, and surgery is delayed for an elective procedure if the A1C value is greater than 8.0. Nicotine levels are also routinely drawn prior to elective surgery on patients with a history of tobacco abuse. The type of anesthesia to be administered is determined by the anesthesiologist and the surgeon. The author prefers for most elective foot and ankle cases that a popliteal and saphenous nerve block be administered preoperatively by the anesthesiologist. This allows for an extended period of analgesia postoperatively compared to an ankle block administered by the surgeon and may decrease the consumption of oral narcotics by the patient in the postoperative period.

4.4.2 Positioning and Equipment • Hardware required for this procedure includes: –– 2 × 2.5 mm cannulated headless screws for the HIPJ fusion

4  Hallux Interphalangeal Joint Arthrodesis and Jones Tendon Transfer

–– Biotenodesis anchor if the Jones tendon transfer is to be performed –– General instrument set –– Sagittal saw The patient is brought to the operating room and placed supine on the table so that the heels are at the edge but not overhanging on the end of the table. General anesthesia is administered to the patient. A well-padded thigh tourniquet is applied and set to 300  mmHg. The foot is then prepped and draped in the normal sterile fashion, the foot is elevated and exsanguinated with an Esmarch bandage, and the tourniquet is inflated.

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#15 blade is utilized to make an incision through the subcutaneous tissue (Fig. 4.3). Adson forceps are used to carefully raise a full thickness flap, and the EHL tendon is exposed and transected distal to the HIPJ and tagged with 0-Vicryl for later transfer into the first metatarsal. The dorsal HIPJ is incised and the collateral ligaments are released (Fig. 4.4).

4.4.4 Technique(s)

A skin marker is used for incision placement planning. The author prefers an S-shaped incision in which the corners of the “S” are nearly 90° (Fig. 4.2). An “S” style incision is centered over the IPJ flexion crease with proximal and distal extensions from opposite sides per surgeon preference or as dictated by local soft tissues. A

4.4.4.1 HIPJ Fusion A 9.5 mm sagittal saw blade is used to resect the head of the proximal phalanx and the base of the distal phalanx (Figs. 4.5 and 4.6). Any transverse plane deformity will be addressed at this time by making bone cuts that are perpendicular to the axis of both the proximal and distal phalanges. Care must be taken to make cuts that are perpendicular to the sagittal plane of each bone to ensure rectus alignment of the digit after internal fixation is placed. The surgeon should be mindful of the underlying flexor hallucis longus tendon when making the cuts so as not to transect it. The amount

Fig. 4.2  A skin marker is used to mark the proposed incision

Fig. 4.3  A full thickness flap is raised down to the level of the EHL tendon

4.4.3 Approach

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Fig. 4.6 The proximal end of the distal phalanx is resected

Fig. 4.4  The dorsal HIPJ is incised and the collateral ligaments released. The EHL tendon is transected at the level of the HIPJ. If the Jones transfer is to be performed, the tendon is whip stitched with 0-Vicryl to be passed into a more proximal incision made over the metatarsal neck

Fig. 4.5  The proximal phalangeal cut is made. Any angular deformity is corrected through this cut

of bone resection required to expose subchondral bone without taking excess bone must be carefully considered so that stable congruent surfaces are available for secure internal screw fixation. Bone ends are further prepared by fenestrating them with a 0.062  K-wire to promote subchondral bleeding. Internal fixation techniques for HIPJ fusion vary among surgeons. Over the years, the author has adopted the use of two parallel headless cannulated screws as the preferred method of fixation. The two-screw construct prohibits any rotational forces across the fusion site. Anecdotally, the author has seen an increased union rate with the two screw technique as opposed to one central screw. Furthermore, internal fixation avoids any pin tract infection or irritation that is seen with the more traditional crossed K-wire fixation. The hallux is plantarflexed at the level of the HIPJ, and two parallel guide wires are driven from proximal to distal through the distal phalanx and out the tip of the toe (Fig.  4.7a). The wires are then retrograded into the proximal phalanx. AP and lateral fluoroscopic views are obtained to confirm wire placement (Fig.  4.7b, c). A 1 centimeter transverse incision is made over the wires at the distal end of the toe, and a cannulated drill is used to drill the cortex of the distal phalanx to allow for 2.5 mm screw placement. (Depending on the size of the bone, larger screws may be used up to 3.5 mm.) With the joint coapted manually, the screw is driven by hand across the HIPJ.  The second 2.5 mm screw is then inserted in the same fashion (Fig. 4.8a, b).

4  Hallux Interphalangeal Joint Arthrodesis and Jones Tendon Transfer

a

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b

c

Fig. 4.7 (a) Two guide wires are driven antegrade and parallel with one another at the end of the hallux. (b) The wires are then driven retrograde into the proximal pha-

lanx. (c) A lateral radiograph confirms wire position within both the proximal and distal phalanges

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a

Fig. 4.8 (a) 2.9  mm screws are placed parallel to one another for increased stability, resistance to rotational forces, and equal compression across the fusion site. (b) A

4.4.4.2 Jones Tendon Transfer The EHL, which was transected at the level of the HIPJ during the initial part of the case, is whip stitched with 0-Vicryl (Fig.  4.9a, b). A 1  cm ­incision is made dorsally at the level of the 1st metatarsal neck overlying the EHL (Fig.  4.10). The tendon sheath is incised, and the transected tendon is pulled proximally into this incision exposing the metatarsal neck (Fig.  4.11a, b). A tendon sizer is used to measure the width of the EHL tendon, and the appropriate size drill is selected (Fig. 4.12). Typically, a 4 mm × 10 mm biotenodesis anchor is used. A guide wire is placed from dorsal to plantar within the metatarsal neck perpendicular to the c­ ortex and passed

b

lateral radiograph confirms the position of both screws within the medullary canal with good bone apposition

a

Fig. 4.9 (a, b) The EHL tendon is transected at the level of the HIPJ, gaining exposure to the joint, and then whip stitched

4  Hallux Interphalangeal Joint Arthrodesis and Jones Tendon Transfer

b

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a

b

Fig. 4.9 (continued)

Fig. 4.10  A skin marker is used to mark the proposed 1 cm incision over the metatarsal neck

Fig. 4.11 (a, b) A hemostat is used to lasso the EHL tendon which is brought up through the proximal incision. If there is difficulty passing the EHL proximally, a small tendon stripper may be used to free the EHL from surrounding soft tissue attachments

Fig. 4.12  The tendon is sized and the appropriate biotenodesis anchor is selected

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a

b

a

b

Fig. 4.14 (a, b) Fluoroscopy confirms the position of the guide wire in the metatarsal neck

Fig. 4.13 (a, b) The guide wire is placed in the metatarsal neck perpendicular to the bone

out the plantar aspect of the foot (Fig. 4.13a, b). The position of the wire is ­confirmed with AP and lateral fluoroscopic views (Fig.  4.14a, b). A 5 mm reamer is placed over the guide wire and driven across both cortices with care being taken not to violate underlying soft tissue structures

(Fig. 4.15a, b). The reamer is removed, and the guide wire, which has a nitinol loop on its end, is left within the pilot hole. The whip stitched 0-Vicryl on the end of the EHL is then placed within the nitinol loop, and the guide wire is pulled manually out the plantar foot bringing the suture with it (Fig.  4.15a–d). The foot is held with the ankle in neutral, and the tendon is placed under anatomic tension, while the biotenodesis anchor is inserted from dorsal to plantar adjacent to the EHL tendon within the bone tunnel (Figs. 4.16a–d and 4.17a–c).

4  Hallux Interphalangeal Joint Arthrodesis and Jones Tendon Transfer

a

b

Fig. 4.15 (a, b) The cannulated reamer is placed over the guide wire, and bicortical drilling is performed

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The distal end of the EHL is sutured to the extensor hallucis brevis tendon using 0-Vicryl in order to maintain a level of muscular balance across the MTPJ. Layered closure is performed with 3-0 Vicryl for subcutaneous tissue and 3-0 Nylon simple interrupted suture for skin. Postoperative dressings include ADAPTIC, 4  ×  4 gauze, two ABD  pads, sterile WEBRIL, and a posterior mold plaster splint.

Intraoperative Pearls and Pitfalls

• Full thickness dissection during initial incision and meticulous handling of the soft tissue are paramount to incision healing. Self-retaining retractors should be avoided. The use of double prong skin hooks by a surgical assistant is utilized throughout the case. • Two screw fixation with headless compression screws which are inserted parallel to one another allows for uniform compression and stability across the fusion site and limits rotational forces. • Skin closure consists of typically no more than five subcutaneous absorbable sutures and six to seven simple interrupted nonabsorbable suture to avoid excess tension on the incision and limit the potential for reaction to the absorbable suture.

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a

b

c

d

Fig. 4.16 (a–d) The suture is passed through the eyelet in the guide wire, and the EHL tendon is pulled through the metatarsal neck

4  Hallux Interphalangeal Joint Arthrodesis and Jones Tendon Transfer

a

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b

c

Fig. 4.17 (a–c) The biotenodesis anchor is inserted with the ankle at 90° and the EHL being held under anatomic tension

4.5

Postoperative Care

• Please refer to Chap. 1 for postoperative protocols for this procedure.

4.6

Potential Complications

• Wound healing problems can be limited by meticulous soft tissue handling and limited use of suture during skin closure. • Fracture of the first metatarsal may occur during reaming. Ensuring the guide wire is centralized with fluoroscopy and selecting the

smallest allowable reamer will decrease the risk of fracture. If fracture occurs, open reduction internal fixation of the metatarsal may be necessary, and the appropriate hardware should be available. • Poor bone stock may not allow for adequate purchase of the biotenodesis anchor. If this is the case, select an anchor one size larger and augment the repair by suturing the EHL tendon to the 1st metatarsal periosteum with 0-Vicryl. Consider prolonging the patient’s course of non-weight-bearing to allow for adequate consolidation of the anchor and screw fixation across the HIPJ.

5

Hammertoes and Claw Toes: Primary and Revision Roberto A. Brandão and David Larson

Abbreviations DIPJ EDL FDL MTP PIPJ

Distal interphalangeal joint Extensor digitorum longus Flexor digitorum longus Metatarsophalangeal joint Proximal interphalangeal joint

5.1

Introduction

Hammertoe and claw toe deformities are common problems treated by all foot and ankle surgeons. Hammertoes present with dorsiflexion at the MTP, plantarflexion at the proximal interphalangeal joint (PIPJ), and extension at the distal interphalangeal joint (DIPJ). Claw toes present with dorsiflexion at the MTP and plantarflexion at both the PIPJ and DIPJ. Hammertoes and claw toes are caused by an imbalance between the extrinsic and intrinsic pedal musculature that can further lead to instability of the less MTPs. Hallux valgus, equinus, and neuropathic disorders lead to increased forefoot loads that cause

R. A. Brandão (*) The Centers for Advanced Orthopaedics, Orthopaedic Associates of Central Maryland Division, Catonsville, MD, USA D. Larson Steward Health Care, Department of Podiatry, Glendale, AZ, USA

biomechanical compensation of the digits and MTPs. Subsequent plantar forefoot pain or metatarsalgia can manifest from plantar plate tearing; attenuation or complete rupture can occur due to these deformities, further complicating treatment plans. Hammertoes can be associated with a pes planus foot type due to excessive flexor stabilization from the long flexors firing for a longer period which overpower the interosseous muscles and can lead to 4th and 5th toe adductovarus rotation. Claw toes are typically associated in patients’ cavus foot type or neuromuscular disease with extensor overcompensation secondary to a weak posterior complex musculature in which the extensor gains advantage over the intrinsic lumbricals.

5.2

Case Example

A 50-year-old female with main complaints of a 2nd digital hammer toe with plantar forefoot-­ associated pain at the 2nd metatarsal head. She has a hammertoe deformity with concerns for a plantar plate tear. The patient has a reducible toe deformity, and a negative Lachman’s test of the 2nd MTP without a  hallux valgus or planus deformity. Plain film radiographs reveal a digit with elevation seen on the lateral view and a “gun barrel” sign on anteroposterior (AP) viewing. There is no angular deformity present, but there is a concomitant elongated 2nd metatarsal. The

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patient has exhausted nonoperative treatments including shoe gear change, custom orthotics, and physical therapy. Magnetic resonance imaging demonstrates no tear of the plantar plate and no neuroma present in the 3rd interspace.

5.3

Presentation/Diagnosis

Digital hammertoe and claw toe deformities can affect patients of all ages and level of activity. Patients will typically present with complaints of toe pain from either dorsal or distal calluses that form secondary to shear forces and repetition friction in shoe gear. Additionally, patient with neurological or spastic disorders may have difficulty wearing certain bracing or shoe gear due to the severe deformity. As previously noted, hammertoes and claw toes often present with other associated foot deformities including equinus contracture, metatarsalgia, and bunion deformity. Flexor stabilization is the most common type of mechanism that results in a hammertoe which can be evaluated and seen in patients as the flexor digitorum longus (FDL) muscle overpowers interosseous muscles. During a gait analysis, compensation of the FDL muscle attempting to supinate the foot can ultimately lead to this deformity. The least common mechanism is flexor substitution, a compensation likley  due to a weak triceps surae muscle group. The FDL muscle tries to compensate for the weak triceps surae and as a result, overpowers the interossei muscles. This may been seen clinically with a chronic Achilles tendon tear or overlengthened Achilles tendon from a previous surgery. As noted prior, extensor substitution is seen in patients with a pes cavus foot type or neuromuscular disease which often results in claw toes. This deformity is seen during the swing phase of gait, and patients typically have some degree of equinus deformity. All hammertoe and claw toe deformities generally follow a three-stage pathology from reducible to semirigid to a final rigid state. A thorough exam should include a history or family history of a neuromuscular disease, gait analysis, and complete lower extremity exam. Predislocation

syndrome or plantar plate injury should also be excluded, especially when a hallux valgus deformity is present. An intermetatarsal neu­ roma, inflamed bursa, or capsulitis must also be ruled out as a contributing factor in any globalized forefoot pathology. Preoperative labs should be considered to evaluate nutritional status (prealbumin, albumin), diabetic control (if applicable), and electrolyte balance (basic metabolic panel). Tobacco use should be discontinued prior to any surgical intervention as this can increase the risk of complications in foot and ankle surgery (Bettin [1]). Hammertoes and claw toe deformities can be treated by either arthroplasty or arthrodesis of the affected joints. For arthrodesis, your choice of equipment can vary based on adjunctive procedures and cosmesis. These choices are part of the preoperative planning stage, and one must have all needed instruments in the room.

5.3.1 Arthroplasty Digital arthroplasty is the resection of the proximal phalanx head in isolation and can indicate semirigid or rigid hammertoes with no other associated varus/valgus angulation or contracture at the MTP. Arthroplasties of the DIPJ and PIPJ shorten the length of the digit and weaken the pull of the flexor complexes which reduce further hammering (Boberg [2]). Arthroplasties are less definitive than an arthrodesis and best for isolated digit deformities and can provide symptomatic relief. One common use for arthroplasty has been for the treatment of the adductovarus 5th digit deformity.

5.3.2 Arthrodesis Arthrodesis of either the PIPJ or DIPJ represents a more definitive procedure with longer lasting results. Whether a bony union or a fibrous stable union, it offers more stability and less chance of recurrence. Additionally, eliminating the deforming force of the digit may prevent further issues at the MTPJ level such as plantar plate injury or

5  Hammertoes and Claw Toes: Primary and Revision

metatarsalgia. It is effective in both extensor- and flexor-based deformities and preferred when multiple digits need to be stabilized in the forefoot (Boberg).

5.3.3 Flexor Tendon Transfer A seldom used procedure in modern surgical practice, it can afford added stabilization without the need for internal fixation of the digit. Transferring power  of the flexor dorsally creates a straight lever arm at the MTP.

5.3.4 Flexor Tenotomy A flexor tenotomy is best utilized for flexible flexion deformities at either the DIPJ or PIPJ level. If a claw toe deformity is present, the FDL should be released at the DIPJ; if a hammertoe is present, releasing both long and short flexors at the PIPJ will reduce the deformity.

5.3.5 Extensor Tenotomy This technique is used for moderate to severe extension deformities of the lesser digits. The release is generally completed proximal to the MTPJ to reduce the contracture prior to the joint level. It can provide relief for flexible hammertoe or in conjunction with other digital surgical correction.

5.3.6 A Note on Local Skin Plasty Z, V–Y, or rotational skin plasty techniques can be used both in the primary setting or revsion if concerns for skin contracture are present when treating a multilevel deformity. Most commonly, a “derotational arthroplasty” can be used on adductovarus 5th digit deformities using an elliptical incision in a distal, medial to proximal lateral direction. Subsequent pinning of the digit can be done for added stabilization but has been described without this addition successfully.

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5.3.7 A  Note on Plantar Plate Pathology Multiplanar digital deformities or plantar plate treatments will not be addressed here. Treatment options and discussion can be found in Chap. 6.

5.4

Imaging

X-rays  AP and lateral plain film radiographs can be used to assess evident contractures by noting a “gun barrel” sign which is associated with a hammertoe deformity as the viewer is seeing the medullary canal of the proximal phalanx. This is similar in claw toe deformities as one can look down the central axis of the distal phalanx. A lateral view is helpful in evaluating the elevation of the digit which may indicate plantar plate insufficiency or associated pathologies. MRI  A magnetic resonance imaging series of the forefoot can be useful to evaluate the plantar plate as well as rule out any soft tissue pathology or interdigital neuromas that may be also present. Additionally, this form of advanced imagining can help detect other osseous pathology including cartilage defects or the presence of the avascular necrosis of the 2nd metatarsal head (most common). Noninvasive vascular studies  Noninvasive arterial studies may be warranted based on patient comorbidities including diabetes mellitus, peripheral vascular disease, history of vasculopathies, or distal peripheral neuropathy. Surgical intervention on digits in immunocompromised or fragile hosts for ulcer prevention may require this full work-up for the healing assessment.

5.4.1 Operating Room Setup The patient is brought into the operative room theatre and placed on the operating table. General anesthesia is then performed via LMA or general intubation. A thigh tourniquet should be applied to the operative extremity. A sequential compression device is placed on the nonoperative extremity. All

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appropriate equipment should be present. An ipsilateral hip “bump” can be valuable as many patients are externally rotated in the lower extremity. Typically, an ortho minor or small procedure tray has all the equipment needed for the procedure. A No. 15 blade is used to incise the skin in an elliptical or liner fashion over the proximal head allowing access to proximal phalanx for resection, and a curette and rongeur are used to resect the cartilage off the base of the middle phalanx.

5.4.2 Equipment Hammertoes 1. A 0.062” K-wire is used in a retrograde fashion through the end of the digit to fixate the PIPJ fusion. 2. Hammer toe implant of the surgeon’s choice.

tal saw is then used to remove the head of the proximal phalanx or middle phalanx. If only performing an arthroplasty, the procedure will end here with layer closure and application of sterile dressing. If performing an arthrodesis, a rongeur and curette is used to resect the cartilage on the respective bases. The fixation for hammertoes includes a 0.062” K-wire that is placed in a retrograde fashion through the digit distally and then inserting the wire into the proximal phalanx. Prior to advancing the K-wire into the associated metatarsal, the digit is generally positioned in a slightly plantarflexed position. If using an implant device, implantation should occur after the area is flushed with good retraction. Various implant systems exist and may contain 2 or 1 component implants that require slightly different compression techniques based on the technology. Appropriate planning and practice should be considered prior to use (Figs. 5.1 and 5.2).

Claw toes 1. 2.5 mm or 3.0 mm fully threaded cannulated screw for intramedullary fixation of the surgeon’s choice. It has been the experience at our institution that this helps to prevent recurrence seen in some patients with claw toe deformities, especially when the etiology is neurogenic in nature.

5.5

Operative Technique

For both hammertoes and claw toes, the surgical technique is similar but can vary based on incisional placement and the materials used for fixation. A 2–3  cm curvilinear incision is made dorsally over the MTP. Dissection is carried down to the extensor tendon, and a Z-lengthening can then be performed. A capsulotomy of the MTP is performed releasing the associated extensor contracture. Next a full thickness elliptical incision is then made dorsally over the PIPJ or DIPJ of the digit. Alternatively, a linear incision is made over the PIPJ or DIPJ, and the extensor tendon is reflected off the bone. (This may be best when preparing both joints to reduce dissection time.) The entire ellipse of skin with the associated extensor tendon is removed. A sagit-

Fig. 5.1  A 52-year-old neuropathic male with flexion contractures at the level of both the DIPJ and PIPJ treated with intramedullary fixation for dual arthrodesis. The patient is now 8 months post-op in normal shoe gear without complications. (Photo credit: G. Berlet MD)

5  Hammertoes and Claw Toes: Primary and Revision

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Fig. 5.2  A 60-year-old male s/p 2nd and 3rd digital PIPJ fusions approximately 7  years ago with good osseous union and stability

Fig. 5.4  A 42-year-old female with 2nd PIPJ fusion via an intramedullary screw not crossing the DIPJ. Concomitant metatarsal osteotomy and a modified Lapidus were also performed

is thinner and is not placed into the metatarsal to breakage. Intraoperative fluoroscopy is used in both AP and lateral viewing to determine optimal placement of the guide wire prior to measuring and pre-drilling. Finally the screw is inserted with good compression across both joints. The digits are instead splinted in a plantarflexed position using sterile 4 × 4 dressings. Closure consists of either 2-0 or 3-0 Vicryl for the deep layers and a 3-0 Monocryl running subcuticular technique or a 3-0 nylon in an interrupted horizontal technique. The tourniquet is let down prior to bandage application to assess for capillary refill. Patients are then placed in a well-padded posterior Jones splint postoperatively (Figs. 5.3 and 5.4). Fig. 5.3  A 73-year-old male 2 weeks status post from a modified Lapidus bunionectomy with a 2nd digit PIPJ fusion, 2nd metatarsal Weil osteotomy, and direct plantar plate repair. (Photo credit: T. Philbin DO)

The fixation for claw toes consists of a 2.5 mm or 3.0  mm cannulated screw placed in a retrograde fashion. The guide wire for this screw type

5.6

Postoperative Protocol

1. All patients are placed into a posterior splint immediately postoperatively. They are seen 5–7 days after surgery, and the incision(s) are checked, and a new sterile dressing is applied.

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2. If no other procedures were performed that require the patient to remain non-weight-­ bearing, then patients are placed into a pneumatic cam walking boot and are advised that they can bear weight as tolerated in the boot. They are required to wear the boot until the K-wires are removed and/or fusion is seen radiographically which is typically 4–6 weeks. At that time, if K-wires were placed, they are pulled, and patients can begin weight-bearing in a regular shoe as tolerated. 3. Radiographs are obtained at the first postoperative visit and at 4 and 8 weeks, 6 months, and 1 year.

Additional Callout/Pearls and Pitfalls for Resident/Fellow Readers

• Use a thigh tourniquet to prevent artificial buckling of the digits as when using an ankle tourniquet. • When using a 0.062” K-wire for fixation, create a pilot hole down the center in the proximal phalanx prior to driving the wire in antegrade fashion out the distal phalanx. This allows more accurate

placement of the wire in the center aspect of the proximal phalanx when driving the wire back in a retrograde direction from the distal aspect of the digit. • When correcting multiple digits, perform all the incisions and dissection at the same time. This allows for an assembly line type joint resection which is more efficient and reduces the surgical time. • For claw toe correction, a 2.5 mm fully threaded cannulated screw is used in lieu of a 0.062” K-wire. This has been shown to decrease the rate of recurrence.

References 1. Bettin CC, Gower K, McCormick K, Wan JY, Ishikawa SN, Richardson DR, Murphy GA. Cigarette smoking increases complication rate in forefoot surgery. Foot Ankle Int. 2015;36(5):488–93. 2. Boberg J, Willis JL.  Digital deformities: etiology, procedural selection and arthroplasty (Chap. 13). In: Banks AS, Downey MS, Martin DE, editors. McGlamry’s forefoot surgery. Philadelphia: Wolters Kluwer Health; 2015.

6

Plantar Plate Instability Jeffrey E. McAlister and Mark A. Prissel

6.1

Introduction

The understanding of lesser metatarsophalangeal joint (MTP) instability has evolved over the years with a better understanding of the pathoanatomy and greater attention to the soft tissue derangement. Historically, lesser MTP pathology was often managed by addressing the osseous pathology alone, with oversight regarding the soft tissue stabilizing structures [1]. The plantar plate is a fibrocartilaginous structure which is a dorsal restraint to the MTP. Deformity occurs when the plantar plate is torn or attenuated. Crossover toe and MTP instability often occur with multiplanar deformity, most commonly with dorsal contracture of the second toe and medial drift over the hallux. Although plantar plate instability can occur secondary to acute injury, the aim of this article is to describe cases where by chronic attenuation causes metatarsalgia and digital deformities and elaborate on preoperative work­up and surgical correction.

J. E. McAlister (*) Arcadia Orthopedics and Sports Medicine, Phoenix, AZ, USA M. A. Prissel Orthopedic Foot & Ankle Center, Worthington, OH, USA

6.2

Patient Presentation

A thorough patient history and physical examination are always performed. In the acute setting, patients will have a history of traumatic injury to the forefoot whereby the toes were forcibly dorsiflexed. Patients will have obvious immediate swelling and typically present in an urgent fashion. In the subacute or chronic setting, plantar plate instability is most commonly present as a complaint of pain to the ball of the foot or concern about a hammertoe. Discussions will typically involve prior history of trauma, inappropriate shoe gear, and concomitant deformities. Understanding a patient surgical history is also important with lesser MTP instability as it is common to have increased pain after a first ray procedure. Discussing any history of rheumatologic disorders is also important in the patient preoperative work-up. It is imperative with digital and forefoot-­ driven pathology to assess patients in a loaded and unloaded fashion. We recommend having the patient cycle through a normal gait and assess the patient in a seated position. As with most forefoot issues, assessing posterior lower leg muscle group tightness is crucial and done first. A standard Silverskoild test is performed to assess for gastroc-soleal equinus. In stance, the hindfoot is assessed for underlying pathology which may be overloading the lesser MTP, such as a pes plano valgus foot type with an insufficient medial col-

© Springer Nature Switzerland AG 2019 C. F. Hyer et al. (eds.), Essential Foot and Ankle Surgical Techniques, https://doi.org/10.1007/978-3-030-14778-5_6

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umn. The medial column is then assessed for instability, and the first MTP is assessed for range of motion. Hallux valgus deformity is frequently present and must be graded clinically and radiographically prior to discussions of lesser MTP correction. Clinical presentation and surgical management of hallux valgus deformity are not the aim of this chapter but are taken into account in the operative algorithm. Focusing on the lesser MTP deformity and pathology is next and most commonly involves the second MTP [8, 10]. One should assess for soft tissue edema and tenderness around the second MTP. In the acute setting, ecchymosis and edema are present plantarly as well as dorsally. Range of motion of the MTP is typically limited and very painful in extreme dorsiflexion. In a crossover toe deformity, a patient will typically have tenderness and pain directly under the metatarsal head. Most often this pain is biased toward the plantar lateral corner of the MTP joint, as the attenuation to the plantar plate occurs to the lateral extent of the structure when a medial crossover toe is present. There also may be a hyperkeratotic lesion plantar to the metatarsal head. A digital contracture is typically involved in both the sagittal and transverse planes, so one should Assess for the flexibility of the PIPJ and DIPJ. In a chronic situation, patients typically have a PIPJ joint contracture and arthritic changes. Clinically, a crossover toe is non-­ reducible and abuts the great toe laterally. Patient also may have a small hyperkeratotic lesion or ulceration on the lateral side of great toe [2, 3] (Fig. 6.1). If a single digit or ray is involved, the other MTPs can be assessed in the sagittal plane. The plantar plate acts as a dorsal restraint, and any small tear along the margin of the plantar plate can cause instability and pain [6]. Specifically, with a dorsal translation of the proximal phalanx on the metatarsal, a “Lachman maneuver or test” will elicit extreme pain. Compared with uninvolved joints, a positive test is at least 50% translation of the width of the proximal phalanx. A discussion is typically regarding concomitant medial column procedures (e.g., first ray) and the associated lesser MTP instability [7]. Discussion regarding dorsal versus plantar

Fig. 6.1  Preoperative examination demonstrates a positive Lachman test of the second metatarsophalangeal joint (MTP) and rigid deformity at the proximal interphalangeal joint. Associated findings of digital contractures may also involve the hallux and posterior leg muscle group [4]

approach is undertaken including the associated complications. It is imperative to have a discussion regarding expectations of digital and forefoot surgery.

6.3

Diagnostic and Imaging Work-Up

Upon initial examination, a standard series of three foot radiographs are taken weight-bearing also including sesamoid axial and calcaneal axial

6  Plantar Plate Instability

views. Anteroposterior radiographs typically demonstrate transverse plane deformity of the proximal phalanx on the metatarsal and will give the surgeon better detail as to the appropriate procedure choice. The associated hallux valgus is assessed. Studies have shown an association of metatarsal length, parabola, and deviation of the lesser toe on the metatarsal with plantar plate tears (Klein [15, 16]). An elongation of the second metatarsal greater than 4 millimeters relative to the first has been shown as a radiographic risk factor for plantar plate tear (Fleischer-Nilsonne method). In a primary case, the authors typically do not perform a Weil osteotomy unless the second metatarsal length is greater than 2–3  mm compared to the first metatarsal, to not create a predictable transfer lesion [11]. The authors do recommend advanced imaging if there is concern for plantar plate tear. Ultrasound and magnetic resonance imaging is useful in determining the status of the plantar plate and associated structures. MRI can also be utilized to identify any cartilage defects in the metatarsal head, AVN, or other differential diagnoses. Multiple studies have shown utility of both modalities. Coughlin et al. have a grading scheme for the severity and location of the tear. The surgeon can appropriately plan for surgical intervention with an appropriate grading scheme, advanced imaging, and clinical work-up [13].

6.4

OR Setup and Instrumentation: Hardware Recommendations

Patients are typically on the operating room table in a supine position. A sandbag bump is placed under the patient’s ipsilateral hip. Typically, general anesthesia and a preoperative popliteal block are utilized during this type of case, and thigh tourniquet is applied to the patient’s operative limb. The small (mini) fluoroscopy unit should be on the same side as the operative leg. Instrumentation typically involves appropriate suture material for lateral collateral ligament repair and plantar plate prepare. Power drivers

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and sagittal saws are utilized for metatarsal osteotomies when indicated. The authors prefer small cannulated screws (2.0, 2.4) or snap-off screws (2.0) for the metatarsal osteotomy and a 2-0 nonabsorbable braided suture for collateral ligament soft tissue repairs when needed. The plantar plate itself may either be repaired with nonabsorbable braided (2-0) or absorbable (0) suture. The hammertoe, when present, is fixed with the surgeon’s preferred method. One may also encounter a plantar plate which is completely nonviable and/ or avulsed from the phalangeal base; in these instances the surgeon will need a small suture anchor.

6.5

Operative Technique: Key Operative Steps

Based on preoperative radiographs and clinical exam, the surgeon applies the appropriate surgical algorithm: • If there is purely sagittal plane deformity and a long metatarsal, then the authors will typically start dorsally and commence with a shortening metatarsal osteotomy and direct plantar approach plantar plate repair. • If the metatarsal parabola is appropriate and anatomic, then a direct plantar approach plantar plate repair is performed in isolation without dorsal exposure or shortening osteotomy. • If the second toe is a medial crossover toe with plantar plate insufficiency, then a translational metatarsal osteotomy (translational Weil or TCMO) is performed, followed by a direct plantar approach plantar plate repair. • The associated hammertoe deformity is often corrected prior to the plantar plate repair; this allows for accurate assessment of the amount of correction required to the plantar plate repair and allows the soft tissue fixation of the plantar plate repair to be performed subsequent to all of the osseous components, therefore, limiting the risk for loss of correction.

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As with most plantar plate pathology, there is typically an associated digital deformity. Of note, the digital deformity is typically addressed prior to any metatarsal osteotomy, plantar plate repair, or associated procedures. We recommend management of the hammertoe through a transverse converging semielliptical incision, which helps prevent any longitudinal contracture on the dorsal surface of the joint. The hammertoe incision should not be continuous with the metatarsal osteotomy incision, if an osteotomy is performed. For this chapter, we will assume the digital deformity was addressed first.

6.6

Direct Plantar Plate Repair

The authors do not routinely perform a dorsal approach to the plantar plate. A direct plantar approach is easy to perform with adequate direct visualization of the pathology. This approach also does not overutilize lesser metatarsal osteotomies, as an osteotomy is not required to improve visualization of the plantar plate from the plantar approach, as is common to dorsal techniques. After appropriately prepping the operative limb to the level of the tourniquet and limb exsanguination, attention is directed toward the plantar aspect of the foot. Another pearl for this specific procedure is to maneuver the operating table into Trendelenburg position. A small gauge K-wire can be advanced from the dorsal aspect of the second MTP through the plantar aspect of the foot to aid in identification of the proper level of the joint at the plantar skin. A linear or curvilinear incision is then made across the plantar MTP. The incision is carried out on the plantar aspect of the foot with care to avoid superficial retraction. The incision is carried down through subcutaneous adipose tissue to the level of the flexor tendon sheath. The flexor sheath is most easy to identify at the distal extent of the incision at the level of the phalangeal base. Often in crossover toe deformities, the flexor tendons are subluxed medially and can be difficult to initially

identify at the level of the MTP or more proximally, if not located distally first. A plantar incision that extends slightly onto the toe itself may help with prevention of floating toe complications, as a small amount of contracture on the plantar surface is actually beneficial to maintain toe purchase to the ground. The flexor tendon sheath is sharply opened. A small Weitlander retractor is utilized to retract the flexor tendons. Once the tendons are retracted, the plantar plate is visualized. Frequently attenuated, dystrophic and hypertrophied tissue is identified rather than a frank full-thickness tear of the tissue [6, 12– 14]. The surgeon will often find a small punctate stellar lesion within the planter plate which is typically excised. The surgeon should take the time to identify the plantar plate attachment onto the proximal phalanx. If one does not have enough fibrocartilage or soft tissue on the plantar aspect of the proximal phalanx, then a small soft tissue anchor is required for adequate correction (Fig. 6.2a–e). When the base of the proximal phalanx is identified and the appropriate amount of soft tissue is available for repair, the surgeon proceeds with resection and direct apposition. The degenerated portion of the plantar plate is debrided and excised. This can either occur as a rectangular resection if no transverse plane deformity is present or as a wedge when transverse plane deformity exists (base lateral, apex medial for the medial crossover toe). The resected tissue volume is based on the degree of degeneration present, but in most instances 2–3  mm of tissue is removed. The digit is appropriately plantarflexed at the MTP, and the plantar plate is directly repaired with a pants-over-vest suture repair. The incision is then closed in layers with absorbable and nonabsorbable sutures. The skin layer is typically closed in a horizontal mattress fashion to provide appropriate eversion of the plantar skin edges. The final toe position of the involved digit should be slightly more plantar than the adjacent toes. The authors avoid pinning across the MTP to further stabilize the joint, except in cases of severe instability (Fig. 6.3a–c).

6  Plantar Plate Instability

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a

b

d

e

Fig. 6.2 (a) Intraoperative photograph of a 2.5 cm curvilinear incision on the plantar aspect of the affected second MTP.  This allows for less soft tissue contracture and avoidance of a painful plantar scar. One may also place the incision between the metatarsal heads. (b) Initial dissection will typically involve adipose tissue, and adjacent to the joint capsule lie the plantar interdigital nerves. (c) After careful dissection, the flexor tendon sheath is visualized, and the flexor tendons are mobilized. This can typically be accomplished with a small Gelpi-type distractor.

c

(d) Directly underneath, or deep, to the flexor tendons lies the plantar (volar) plate. In this case, the planned plantar plate resection is highlighted in marker. (e) Carefully, a wedge of the thick fibrocartilaginous plantar plate is excised with a blade. Care is taken to avoid resecting off of the proximal phalanx. When the surgeon encounters a small punctate tear or no residual plate available on the proximal phalanx, a small anchor (2.0–3.0 mm) may be utilized to secure the proximal leading edge

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a

b

c

Fig. 6.3 (a) After excising the wedge of soft tissue, a 2–0 nonabsorbable suture is utilized to repair the defect. Typically the toe is held in a slightly overcorrected a­ ttitude

while performing the repair. (b) Final construct with the second toe slightly plantarflexed. (c) Skin closure

6  Plantar Plate Instability

6.7

Metatarsal Osteotomy

The shortening Weil metatarsal osteotomy is described in detail within the relevant chapter. When appropriate, the metatarsal osteotomy is completed prior to correction of the plantar plate. Some subtle modifications of this utilitarian osteotomy can be applied to aid in correction of plantar plate pathology and crossover toe deformities. Mild abnormalities in the metatarsal parabola can exacerbate the force through the pertinent MTP and result in chronic plantar plate deformity and pain when the deformity only involves the sagittal plane a shortening Weil osteotomy. More commonly, especially in the instance of the crossover toe, transverse plane deformity is present. One option is to perform a standard Weil osteotomy with typically shortening of 2–3 mm, but prior to fixation the capital fragment can be translated up to 50% (with care taken not to rotate the cartilaginous surface) to assist in relocating the toe to a neutral position in the transverse plane. In the example of a medial crossover toe, the capital fragment is translated medially, and in a laterally deviated deformity, the capital fragment is translated laterally. Ancillary procedures are often involved, regardless of the presence of transverse plane deformity. The extensor tendons can be Z-lengthened or tenotomized based on surgeon preference. The authors typically perform a tenotomy or lengthening of the extensor digitorum longus and brevis as they are a strong deforming force. The dorsal capsule is often contracted and a sagittal plane deforming force, so a capsulotomy is essential to perform the osteotomy and lesser toe correction; however, as appropriate a dorsal capsulotomy can be considered regardless of the requirement for an osteotomy. When fixating the osteotomy, the authors prefer two points of fixation to prevent rotation of the capital fragment, especially when medial (or lateral) translation is employed. Final position is then confirmed on intraoperative fluoroscopy for translation and correction. The redundant dorsal metatarsal is then resected with a small bone cutter or rongeur. Upon closure, the MTP capsule is not closed, as this will cause a reformation of the deformity. Closure is performed in layers based on surgeon’s preference.

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6.8

Triplane Correctional Metatarsal Osteotomy

Crossover toe correction can be performed in a sequential manner. The following steps are for a dorsomedial crossover toe deformity. A standard curvilinear incision is performed over the affected MTP.  Dissection is carried down through the superficial fascia cauterizing superficial vessels. Care is taken specifically to isolate the medial collateral ligaments as well as lateral collateral ligaments. With this deformity, the lateral collateral ligament is typically attenuated, while the medial collateral ligament is ­contracted [9]. Once this is performed, a dorsal transverse tenotomy and MTP capsulotomy are performed which allow for reduction in the sagittal plane. Next, care is taken to transect the medial and lateral collateral ligaments in the mid-­ substance of the ligament. If the collateral ligament is transected too close to the phalanx, then there will be very little collateral ligament to repair. This is most acutely important on the lateral aspect of the MTP. Next, the dorsal aspect of the metatarsal head is cleared of capsular tissue with the rongeur or sharp blade. An osteotomy is then performed at the metatarsal neck about 3–4  mm proximal to the dorsal cartilage. The sagittal sawblade is angled dorsal to plantar toward the deformity of the toe, most commonly medially. Typically, the surgeons recommend also slight angulation proximal to distal. The capital fragment is then translated: medial, proximal, and dorsal. The recommended amount of translation is typically one third of the width of the metatarsal, or about 3  mm. The osteotomy lends itself to a screw being placed from medial distal to lateral proximal. The capital fragment is first temporarily fixated with a small K-wire and visualized under intraoperative fluoroscopy. The MTP should be relocated and a clear joint line should be seen. The digit should be seen well aligned with the capital fragment. The capital fragment is then fixated with a small cannulated screw or snap-off screw. The redundant lateral metatarsal neck is not typically resected, as this will inherently remove the remaining lateral collateral ligament.

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The toe is then held in an appropriate position, and the lateral collateral ligament is repaired with a 2-0 nonabsorbable suture. The operative pearl during this procedure is to place the lateral collateral ligament repair on the plantar lateral aspect of the MTP. Typically, only one suture is needed. The MCL is not repaired. The authors do not routinely use K-wires during this approach, and this avoids necessity of K-wires traversing the MTP and possibly causing a AVN or arthritis (Fig. 6.4a–c). The incision is then closed in layers with absorbable sutures and skin closure based on surgeon’s preference.

6.9

Postoperative Protocol

This surgery falls into postoperative protocol #2. The standard dressing applied to the operative limb is a sterile well-padded Jones compression dressing with posterior splint. Appropriately ban-

daging the affected digit and surgical site in slight plantar flexion with these procedures is paramount (Fig. 6.5a, b). Specific to these procedures, the authors recommend a period of non-weight-­ bearing approximately 7–10 days and then transitioning the patient to a pneumatic walking boot with protected weight-bearing until week 6. A removable stabilizing splint can be applied to maintain slight plantarflexion position and stability. Sutures are then removed based on patient’s healing potential and when the incisions have healed appropriately. At week 6, the patients are transitioned back into a stiff-soled athletic shoe and physical therapy initiated to aid in range of motion and gait. A main focus of physical therapy is to prevent dorsal scar contractures and maintain appropriate motion in plantarflexion, as normal walking will provide appropriate motion for dorsiflexion. Custom fabricated orthoses are typically fashioned at 6–8  weeks postoperative. Serial radiographs are used to confirm healing of the osteotomies and that no complications

a Fig. 6.4 (a) Transverse plane deformity may also be corrected as seen here. This illustration depicts an angular osteotomy in the metadiaphyseal portion of the distal metatarsal. This angled cut is made perpendicular to the proximal phalanx and is shifted in the direction of the

deformity. The collateral ligaments are repaired appropriately. (b) Anteroposterior preoperative and postoperative (c) weight-bearing radiographs of a strictly transverse plane deformity corrected with an oblique osteotomy

6  Plantar Plate Instability

b

65

c

Fig. 6.4 (continued)

a

Fig. 6.5 (a) Clinical photograph 1  week postoperative demonstrating intentional positional overcorrection of the second toe. Note dorsal Weil osteotomy incision does not extend beyond the MTP joint or onto the second toe.

b

(b) Clinical photograph 1 week postoperative demonstrating incision placement and suturing technique for wound incisional closure

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have  occurred. Patients are appropriately followed for 6–12 months for maintenance of correction and improved functional outcome measures (Figs. 6.6a, b and 6.7a, b).

a

b

Fig. 6.6 (a) Clinical photograph of same patient in Fig. 6.5 3  months postoperative demonstrating barely visible mature plantar incision without hyperkeratotic formation. (b) Clinical photograph of same patient in Fig. 6.5 3 months postoperative demonstrating appropriate alignment and purchase of the second toe. Note the dorsal incision for the Weil osteotomy is more visible than the plantar approach plantar plate repair incision

J. E. McAlister and M. A. Prissel

Pearls, Pitfalls, and Resident Resource

• When performing a metatarsal osteotomy and hammertoe correction along with a plantar plate repair, the osseous procedures (i.e., hammertoe and metatarsal osteotomy) should be performed prior to the plantar plate repair to minimize the risk of attenuating the repair. • Dorsal incisional planning is critical. The advantage of the direct plantar approach is that the dorsal incision can be strategically placed and minimal as extensive dorsal dissection is not required. A Weil osteotomy can be properly performed with an incision that does not extend distally beyond the MTP (i.e., extension onto the toe is not necessary and can increase iatrogenic dorsal contracture). If extending across the MTP, a curvilinear incision is the most important aspect of the technique, which prevents contracture over the MTP.  In revision cases, a V-to-Y or Z-plasty is commonly utilized to correct for soft tissue contractures. • With a shortening metatarsal osteotomy, Weil osteotomy, only 2–3 mm of decompression is necessary for adequate correction. A shortening Weil osteotomy can be translated up to 50%. Especially when translated, consideration for two points of fixation is warranted. • With a triplanar correctional metatarsal osteotomy (TCMO), translate at least one third of the width of the metatarsal. The capital fragment can also be translated dorsally approximately 1–2 mm. • An easy way to determine the angle of the TCMO is to face the sagittal saw in the direction of the deformed digit. • The translational triplanar angular osteotomy of the metatarsal can also

6  Plantar Plate Instability

be utilized for a lateral crossover toe as well. This can be accomplished by performing the techniques in reverse attitude. • Weight-bearing is allowed at 7–10  days following surgery with boot immobilization and removable splintage of the affected toe.

a

Fig. 6.7  Clinical photographs 3  months postoperative dorsal (a) depicting mature incisional healing of transverse converging semielliptical second digit incision for PIP fusion and separate Weil osteotomy incision which

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• Interestingly in cases where both dorsal and plantar incisions are utilized, the plantar incision actually heals with less hypertrophy and is more difficult to visually appreciate. The heavy plantar epidermal layer typically sloughs at approximately 6 weeks, revealing an underlying thin and supple mature scar.

b

does not extend across the MTP or onto the second toe with appropriate deformity correction and plantar (b) depicting mature, healed, barely visible incision for second MTP plantar plate repair with direct plantar approach

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References 1. Barouk LS.  Forefoot reconstruction. 2nd ed. Paris: Springer; 2005. p. 255–68. 2. Blitz NM, Ford LA, Christensen JC.  Plantar plate repair of the second metatarsophalangeal joint: technique and tips. J  Foot Ankle Surg. 2004;43(4): 266–70. 3. Bouche RT, Heit EJ. Combined plantar plate and hammertoe repair with flexor digitorum longus tendon transfer for chronic, severe sagittal plane instability of the lesser metatarsophalangeal joints: preliminary observations. J Foot Ankle Surg. 2008;47(2):125–37. 4. Deland JT, Sung IH. The medial crossover toe: a cadaveric dissection. Foot Ankle Int. 2000;21(5):375–8. 5. Deland JT, Lee KT, Sobel M, DiCarlo EF. Anatomy of the plantar plate and its attachments in the lesser metatarsal phalangeal joint. Foot Ankle Int. 1995;16(8):480–6. 6. Devos Bevernage B, Deleu PA, Leemrijse T.  The translating Weil osteotomy in the treatment of an overriding second toe: a report of 25 cases. Foot Ankle Surg. 2010;16(4):153–8. 7. Doty JF, Coughlin MJ. Hallux valgus and hypermobility of the first ray: facts and fiction. Int Orthop. 2013;37(9):1655–60. 8. Ellis SJ, Young E, Endo Y, Do H, Deland JT. Correction of multiplanar deformity of the second toe with metatarsophalangeal release and extensor brevis reconstruction. Foot Ankle Int. 2013;34(6):792–9. 9. Goforth WP, Overbeek TD, Odom RD, Roe TG, McDonald DK.  Lesser-metatarsal medial displace-

J. E. McAlister and M. A. Prissel ment osteotomy for the treatment of digital transverse plane deformities. J  Am Podiatr Med Assoc. 2005;95(6):550–5. 10. Helal B.  Metatarsal osteotomy for metatarsalgia. J Bone Joint Surg. 1975;57(2):187–92. 11. Highlander P, VonHerbulis E, Gonzalez A, Britt J, Cubhman J.  Complications of the Weil osteotomy. Foot Ankle Spec. 2011;4:165–70. 12. Johnston RB 3rd, Smith J, Daniels T.  The plantar plate of the lesser toes: an anatomical study in human cadavers. Foot Ankle Int. 1994;15(5):276–82. 13. Nery C, Coughlin MJ, Baumfeld D, Raduan FC, Mann TS, Catena F.  Prospective evaluation of protocol for surgical treatment of lesser MTP joint plantar plate tears. Foot Ankle Int. 2014;35: 876–85. 14. Prissel MA, Hyer CF, Donovan JK, Quisno AL.  Plantar plate repair using a direct plantar approach: an outcomes analysis. J  Foot Ankle Surg. 2017;56(3):434–9. 15. Roukis TS, Landsman AS. Hypermobility of the first ray: a critical review of the literature. J  Foot Ankle Surg. 2003;42(6):37–390. 16. Rush SM, Christensen JC, Johnson CH. Biomechanics of the first ray. Part II: metatarsus primus varus as a cause of hypermobility. A three-dimensional kinematic analysis in a cadaver model. J Foot Ankle Surg. 2000;39(2):68–77. 17. Trnka HJ, Nyska M, Parks BG, Myerson MS.  Dorsiflexion contracture after the Weil ­osteotomy: results of cadaver study and three-dimensional analysis. Foot Ankle Int. 2001;22(1):47–50.

7

1st MTP Fusion: Primary and Revision William T. DeCarbo and Michael D. Dujela

7.1

Introduction

The gold standard surgical management of advanced degenerative 1st metatarsophalangeal arthritis is arthrodesis. Additionally, geriatric patients with hallux valgus deformities are well served by fusion of the 1st MTP joint which provides a definitive solution with a high rate of success. The primary benefit of fusion is resolution of pain, increased stability of the entire medial column, and enhanced gait [1]. Refinement of fusion alignment and fixation has resulted in a dependable, reproducible procedure with high patient satisfaction [2]. An important consideration in the decision-­ making in surgical management of hallux rigidus or deformity patients is to determine a patient’s tolerance for more than one surgery. In some instances, a patient with moderate to significant arthritis may be a good candidate for an attempt at joint preservation via cheilectomy. The discussion should center around the probability for progression of the disease and high likelihood of additional surgery in the future. Through mutual agreement, a determination of whether a patient is a “one and done” personality or is willing to

W. T. DeCarbo (*) St. Clair Hospital, Department of Podiatric Surgery, Pittsburgh, PA, USA M. D. Dujela Washington Orthopaedic Center, Centralia, WA, USA

risk the potential for residual pain and need for revision surgery in the future. If the patient is not tolerant of the potential for revision or additional procedures, 1st MTP fusion should be the index operation for moderate to severe degenerative arthritis.

7.2

 atient History and Physical P Examination

A thorough history and physical examination is performed. The history should elicit whether pain is present throughout range of motion or primarily at end range of motion. Specific triggers such as flexible shoe gear, elevated heels, or impact activities should be noted. It is important to assess whether there is a history of a single traumatic episode, episodic injuries, or chronic recurrent abuse such as specific sports or dance. An important consideration is whether there is a history or physical findings consistent with an inflammatory arthropathy which could increase the risk of healing complication such as nonunion. This may impact the choice of fixation. The patient is evaluated while both weight-­ bearing and non-weight-bearing. Specific attention is given to quantitative range of motion of the 1st MTP, quality of motion, and level of discomfort elicited with palpation and motion. It is important to differentiate true structural limitation versus functional hallux limitus/rigidus

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which occurs during gait only. True structural limitus is associated with altered morphology of the joint including narrowing and marginal osteophyte formation that restricts joint motion. Functional limitus is due to altered first ray mechanics or soft tissue restriction. Joint-preserving procedures such as cheilectomy are best reserved for pain at end range of motion or mild to moderate disease primarily affecting the dorsal one-third of the articular surface. When pain and in many cases crepitus is present at various points throughout the arc of motion, rather than exclusively at maximum dorsiflexion, cheilectomy is contraindicated. Significant pain, limitation of dorsiflexion, antalgic gait as well as radiographic features consistent with degenerative arthritis are indications for fusion. It is important to assess dorsiflexion and plantarflexion as well as plantar MTP tenderness which can indicate metatarsal-sesamoid disease. Prognosis is poor with cheilectomy alone in the presence of arthritic sesamoid involvement. It is crucial to evaluate for presence of deformity, crepitus, and edema and to assess the quality of range of motion of adjacent joints. Specific attention is given to the 1st tarsometatarsal and hallux interphalangeal joints to determine if arthritis, deformity, or pain is present which may be magnified after 1st MTP fusion. Weight-bearing static analysis is performed to assess for associated deformity or malalignment. Gait analysis is performed to assess if lateral overload is occurring due to compensation secondary to pain during propulsion.

not validated, it remains useful as it guides decision-making when combined with the clinical findings. Another classification was proposed by Coughlin and Shurnas and combines radiographic assessment of osteophytes with clinical range of motion [4]. This is sufficient for the vast majority of patients; however, in patients with significant deformity, prior trauma, or bone loss, a CT scan is a valuable adjunct. When patients present with vague pain and minimal radiographic findings, an MRI can often elucidate whether a subtle osteochondral defect or plantar sesamoid disease is present as evidenced by cartilage loss, cystic formation, and bone marrow edema.

7.3

Once the patient is prepped and draped in normal fashion, attention is directed to the dorsal medial aspect of the fist metatarsophalangeal joint. A  full-thickness incision is made just medial to the extensor hallucis longus tendon approximately 5 cm in length (Figs. 7.1 and 7.2). Full-thickness dissection without layers is completed through the capsule. Hemostasis is achieved with electrocautery, and care is taken to protect the medial dorsal cutaneous nerve.

Imaging and Diagnostic Studies

A complete series of weight-bearing radiographs in angle and base of gait is the gold standard for evaluation of 1st MTP osteoarthritis or deformity. The most commonly used classification proposed by Hattrup and Johnson describes the presence of osteophytes, joint space narrowing, sclerosis, and cystic formation [3]. While this classification is

7.4

OR Setup/Instrumentation/ Hardware Selection

The patient is placed in a supine position with a bump under the ipsilateral hip so the foot and ankle are rectus on the operating room table. A thigh tourniquet is utilized to keep the surgical field clear from the drapes. General anesthesia is preferred with a popliteal block to reduce postoperative pain. The preferred instrumentation is power drivers with cup and cone reamers. The preferred fixation technique is a dorsal locking plate/screws with a 3.0 cannulated screw used for interfragmentary compression.

7.4.1 Operative Technique

7  1st MTP Fusion: Primary and Revision

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Fig. 7.2  Dorsal medial incision

Fig. 7.1  Dorsal medial incision

Once the joint is accessed, a self-retaining retractor is utilized (Figs. 7.3 and 7.4). A sagittal saw is used to resect the medial, lateral, and dorsal exostosis off the 1st metatarsal head (Figs. 7.5 and 7.6). These portions of the bone are removed and passed from the operative site. Attention is then directed to the base of the proximal phalanx where any bony exostoses are removed with a rongeur. Care is taken to preserve the integrity of the base of the proximal phalanx and to maintain the cortical integrity to allow stable apposition with the head of the 1st metatarsal. Cup and cone reamers are then utilized to denude any remaining cartilage from the head of the 1st metatarsal and base of the proximal phalanx and

Fig. 7.3  Full-thickness subperiosteal dissection

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Fig. 7.6  Medial eminence removed with a sagittal saw

Fig. 7.4  Access into the joint

Fig. 7.5  Dorsal exostosis removed with a sagittal saw

to debride the subcondral bone plate and decompress the joint to facilitate positioning of the 1st MTP and reduction of deformity without interference of any soft tissue-­deforming forces. A guide wire is placed in the central aspect of the 1st metatarsal head and driven into the medullary canal (Figs. 7.7 and 7.8). The appropriatesized cup reamer which closely matches the contour and size of the 1st metatarsal head is chosen. This is usually an 18  mm, 20  mm, or 22 mm cup reamer. The cup is then placed over the guide wire to denude the articular surface of the 1st metatarsal (Figs.  7.9 and 7.10). Care is taken to gently debride this area again being mindful to maintain the integrity of the bone. Excessive pressure may result in inadvertent shortening, particularly in patients with poor quality bone. Once completed, a rongeur is used to remove any remaining bone prominences from the 1st metatarsal head. The guide wire is then removed and utilized to fenestrate the 1st metatarsal head (Fig.  7.11). An alternative is a

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Fig. 7.7  Guide wire for cone reamer placed in center of 1st metatarsal head Fig. 7.9  Cone reamer utilized to denude remaining articular cartilage

Fig. 7.10  1st metatarsal head of cone reamer Fig. 7.8  Guide wire for cone reamer placed in center of 1st metatarsal head extending down metatarsal canal

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Fig. 7.11  1st metatarsal head fenestrated with a drill tip wire

Fig. 7.13  Cup reamer is used to denude cartilage. Hallux must be in maximal plantarflexed position to avoid the reamer hitting the 1st metatarsal head

Fig. 7.12  Guide wire for cup reamer placed

small diameter drill bit such as a 2.0 to penetrate the subchondral plate. The guide wire is then placed into the base of the proximal phalanx of the hallux to align the cone reamer. Because of the morphology of the proximal phalanx being

more concave plantarly, the guide wire is placed slightly dorsal to the center point of the joint (Fig.  7.12). The corresponding size to the cup reamer is used to denude the cartilage/subchondral bone of the base of the proximal phalanx. Care is taken to maintain the integrity of the cortical base of the phalanx to ensure good apposition of the joint and to accept the land of the interfragmentary screw for compression (Figs.  7.13 and 7.14). Once the cone is completed, the guide wire or drill bit is again used to fenestrate the base of the proximal phalanx (Fig. 7.15). Once complete, a ¼ inch osteotome is used to “fish-scale” both the head of the 1st metatarsal and the base of the proximal phalanx (Fig. 7.16). This has to be done gently to create bleeding surface areas of cancellous bone, however with care taken to avoid completely fragmenting the site where the morphology is altered creating uneven fit.

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Fig. 7.16  1st metatarsal head “fish-scaled”

Fig. 7.14  Careful attention is taken to maintain the cortical rim of the base of the proximal phalanx

Fig. 7.17  Prepared 1st metatarsal head

Fig. 7.15  Base of the proximal phalanx fenestrated with drill tip wire

A straight plate is preferred for the 1st MTP fusion. A pearl for alignment is to reduce the prepared 1st MTP joint and place the 1st MTP straight fusion plate dorsally spanning the area (Fig.  7.17). If the plate does not sit flush, a

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Fig. 7.18  Plate positioned with temporary fixation pins to set the proper fist MTP alignment. Guide wire for intra-­ fragmentary screw placed while dorsal plate is setting the position

r­ongeur can be utilized to remove any bony prominences. Once the plate sits flush over the dorsal segment, it is temporarily stabilized with provisional fixation. This ensures the correct alignment of the 1st MTP. The guide wire for the 3.0 cannulated screw is then placed across the joint for interfragmentary compression. This wire can be placed from any orientation to cross the joint. The authors’ preferred orientation is from the medial base of the proximal phalanx to the lateral cortex of the 1st metatarsal (Figs. 7.17 and 7.18). Once the guide wire is placed, the dorsal plate can either be completely removed or the surgeon can just remove one of the provisional fixation pins to allow joint compression as the screw is inserted. The guide wire is measured for appropriate screw size allowing a bi-cortical bite for added compression and stability. Another pearl is once the wire is measured to advance the wire through the lateral cortex of the 1st metatarsal and attach a hemostat to the wire. This will ensure the wire

Fig. 7.19 Guide wire can be thrown under C-arm fluoroscopy

will not be pulled out by the over-drill during this step. The screw is then inserted over the wire into two-finger tightness (Fig. 7.19). Care is taken not to over-tighten the screw and lose the compression/stability of the fixation. A 3.0  mm cannulated screw is chosen to allow as much bone surface apposition between the base of the proximal phalanx and the 1st metatarsal head as possible for bony trabeculation. That said, a 4.0 mm screw can also be used per the surgeon’s preference. Once the interfrag screw is placed, the dorsal 1st MTP plate is reapplied with bi-cortical locking screws (Figs. 7.20 and 7.21). Deep and subcutaneous layers are closed with absorbable suture and the skin with nylon or

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Fig. 7.22  Final construction with interfragmentary screw and locking plate Fig. 7.20  Intra-fragmentary screw placed. The distal provisional fixation pin is removed to allow compression

surgeon’s preference (Fig. 7.22). A well-padded Jones compression dressing with posterior splint is applied (Figs. 7.23, 7.24, 7.25, and 7.26).

7.4.2 Revision Surgery

Fig. 7.21  Locking screw placement into the plate

For revision surgery of the 1st MTP, the same setup and surgical approach as described above is utilized. The primary difference in the technique is removing all previous hardware and nonviable bone. Attention has to be made to restore any bone segmental loss at the nonunion or malunion site. If a nonunion or malunion occurs with minimal bone loss, a revision surgery can be performed in a straightforward fashion similar to the primary surgery (Figs.  7.27, 7.28, and 7.29). Consideration should be given to the selection of alternative fixation choices for the revision surgery. In cases where there is or will be substantial bone loss due to the revision, the length of the first ray must be maintained. This is typically

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Fig. 7.23  Final closure and clinical position

done with bone grafting. The surgeon can use either autogenous bone from the iliac crest or calcaneus or allograft bone from the bone bank. The authors prefer allograft iliac bone to minimize second-site morbidity in the patients. Once the joint is exposed in the fashion previously described, all of the current hardware is removed. The non- or malunion site is assessed,

Figs. 7.24 and 7.25  AP and lateral pre-op x-rays

and the fibrous tissue is resected until bleeding bone margins are obtained. The graft, if needed, is then fashioned to fit the defect while maintaining the appropriate length of the first ray and ensuring good bone to graft apposition of the graft-1st

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Figs. 7.26 and 7.27  AP and lateral post-op x-rays

metatarsal and graft-base interface of the proximal phalanx (Figs. 7.30, 7.31, 7.32, and 7.33). Often a longer more robust plate is utilized in revision cases (Fig. 7.34). If possible an interfragmentary compression screw is again utilized not only to provide compression across the bone segments but also to provide stability to the graft and prevent any shear forces at the graft-bone interfaces.

Figs. 7.28 and 7.29  AP and lateral x-ray of a mal-/non-­ union 1st MTP

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Fig. 7.30  Clinical photo of malunion with abnormal pressure at the tip of the hallux Fig. 7.32  Size of graft determined once deformity and fibrous tissue resected

Fig. 7.31  Osteotomy made at the apex of the deformity

Fig. 7.33  Graft fashioned according to bone defect and placed into bone void

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Fig. 7.34  Intraoperative picture with plate spanning the joint and bone graft

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Fig. 7.37  Photo of clinical alignment depicting toe purchase with lack of abnormal pressure at tip of the hallux

Once the bone segments are compressed and stabilized, a dorsal locking plate is utilized to span the surgical site. External fixation may be considered or needed if the amount of bone resection required does not allow for appropriate internal fixation (Figs. 7.35, 7.36, and 7.37).

7.5

Figs. 7.35 and 7.36  AP and lateral post-op x-rays

Postoperative Management

The initial postoperative dressing applied in the operating room consists of a well-padded sterile dressing with a modified Jones compression dressing and posterior splint. The patient is seen for first postoperative visit between 10 and 14  days after the procedure, and sutures are removed. Radiographs are taken at this visit to confirm appropriate alignment and hardware placement. The patient is placed in a full-length fracture (cam) walker, and if the wound is dry and stable, full heel-touch weight-bearing is encouraged, and gentle forefoot pressure (weight of leg) is possible to tolerate with crutch or walker assistance. The patient is encouraged to remove the boot several times per day to work on foot and ankle ROM exercises. Several studies have shown high union rate with immediate weight-bearing after this technique. Berlet and Hyer reported 91% clinical and radiographic union in 37 patients after immediate weight-bearing protocol for 1st MTP arthrodesis [5]. After sutures are removed, the patient may progress to full WB as tolerated while wearing

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the boot. Radiographs are repeated at 6  weeks post-op, and patient may gradually transition back to a supportive shoe with orthotic support or carbon fiber insert when there is radiographic evidence of early consolidation. Patients are followed for 6–12 months postoperatively to ensure satisfactory outcome.

7.6

Potential Complications

Complications are similar to arthrodesis procedures at other locations in the foot and can be divided into the following categories: 1. Malunion 2. Nonunion 3. Hardware-associated complications Malunion  – Position is key to a successful outcome after 1st MTP arthrodesis. The deformity can be over or under corrected, and transverse plane adduction can result in excessive pressure to the distal medial hallux resulting in poor tolerance of shoe wear. In the case of a significant hallux valgus deformity, residual malalignment can remain when the deformity is under corrected. Recent studies have demonstrated that a significant reduction in the hallux valgus angle and IM 1–2 can occur [6]; however if the intermetatarsal angle is beyond the limits of the procedure, correction may be insufficient and a residual deformity may persist. Care is taken to parallel the second toe, but to avoid pressure against it which can result in an overlapping second digit or ulceration between the toes. Excessive dorsiflexion can result in overload to the 1st metatarsal and sesamoid apparatus, as well as hammering of the hallux at the IPJ. Insufficient dorsiflexion will result in excessive pressure to the distal hallux and potential for IPJ pain and arthritis. There is increased risk of distal skin lesions that may progress to ulceration. Hardware pain – A dorsal plate can be irritating and palpable requiring removal in a moderate percentage of patients. This is quite common in females with minimal subcutaneous fat, and it is

ideal to discuss potential need for hardware removal during the preoperative consent visit. A pseudoarthrosis can occur after 1st MTP arthrodesis, and while this may be well tolerated in many patients, over time fatigue failure of the plate can occur. When the fixation or surrounding bone fails, the previously asymptomatic fusion site may become symptomatic and require ­revision. Careful observation is indicated with serial radiographs recommended for the first 12–18  months in these cases. Nonunion is rare and the frequency has traditionally been overstated. This is typically due to poor apposition of the arthrodesis site, insufficient joint preparation, or inappropriate fixation. Poor intrinsic patient factors such as a vitamin D deficiency or dense neuropathy can increase the risk of nonunion. Lifestyle factors such as poor nutrition, alcohol abuse, or smoking can also increase the risk of nonunion. A systematic review of the literature by Roukis et  al. demonstrated an overall nonunion rate of 5.4%; however the rate of symptomatic nonunion was only 1.8% [7]. With appropriate joint preparation, modern fixation techniques, and recognition of patient factors that can be modified, the rate of nonunion is very low.

Pearls

1. Cup and cone reamer allows positioning and deformity correction in all three planes. 2. Must denude all cartilage through the subchondral bone plate, fenestrate and fish-scale. “Make it look like a bomb went off.” 3. Use dorsal plate to “set” the position of the 1st MTP. 4. Attach hemostat to intra-fragmentary guide wire above measuring to prevent wire being removed by the over-drill. 5. Remove one of the dorsal plate temporary fixation pins when inserting intrafragmentary screw for compression. 6. A thin carbon fiber insert post-op can stress from the surgical site until complete union is achieved.

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References 1. Brodsky JW, Baum BS.  Prospective gait analysis in patients with first metatarsophalangeal joint arthrodesis for hallux rigidus. Foot Ankle Int. 2007;28(2):162–5. 2. Goucher NR, Coughlin MJ. Hallux metatarsophalangeal joint arthrodesis using dome-shaped reamers and dorsal plate fixation: a prospective study. Foot Ankle Int. 2006;27(11):869–76. 3. Hattrup SJ, Johnson KA. Subjective results of hallux rigidus following treatment with cheilectomy. Clin Orthop Relat Res. 1988;(226):182–91.

83 4. Coughlin MJ, Shurnas PJ. Soft-tissue arthroplasty for hallux rigidus. Foot Ankle Int. 2003;24(9):661–72. 5. Berlet GC, Hyer CF, Glover JP.  Retrospective review of immediate weightbearing after first metatarsophalangeal joint arthrodesis. Foot Ankle Spec. 2008;1(1):24–8. 6. McKean RM, Bergin PF, Watson G, et al. Radiographic evaluation of intermetatarsal angle correction following first MTP joint arthrodesis for severe hallux valgus. Foot Ankle Int. 2016;37(11):1183–6. 7. Roukis TS.  Nonunion after arthrodesis of the first metatarsal-phalangeal joint: a systematic review. J Foot Ankle Surg. 2011;50(6):710–3.

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Interpositional Arthroplasty for the First Metatarsophalangeal Joint Patrick E. Bull, James M. Cottom, and Geoffrey Landis

8.1

Introduction

Treatment of advanced first metatarsophalangeal joint (MTPJ) arthritis has many options. Choosing the appropriate treatment strategy for first MTPJ arthritis is dependent upon many factors. The use of an interpositional arthroplasty is an attractive option for younger and active patients with severe (Coughlin and Shurnas Grade III and IV) MTPJ arthritis as it preserves motion and avoids the activity limitations, restricted shoewear options, and stiffness associated with arthrodesis [1–5]. Interposition arthroplasty procedures allow the surgeon to successfully address both the pain and discomfort resultant from arthritic first MTPJ changes without compromising joint bone stock, metatarsal length, and joint stability as are commonly encountered after joint hemi- and total arthroplasty [2, 3]. Furthermore, joint arthrodesis  complications such as nonunion, among ­others, are avoided [2, 6]. In addition, interposition arthroplasty techniques allow for future ­arthroplasty or arthrodesis at a later date should further joint deterioration occur [2]. Lastly, our

P. E. Bull (*) Orthopedic Foot & Ankle Center, Worthington, OH, USA J. M. Cottom Florida Orthopedic Foot & Ankle Center, Sarasota, FL, USA G. Landis Northwest Medical Center/Oro Valley Hospital, Department of Orthopedic Surgery, Tucson, AZ, USA

technique also resurfaces the metatarsosesamoid joints, which are left untreated by nearly all other surgical treatments and have potential to produce postoperative pain [2]. In this chapter we will review our preferred method for first MTPJ interpositional arthroplasty utilizing an allograft regenerative tissue matrix (RTM).

8.2

Patient History/Preoperative Work-Up/Case Examples

Patients with advanced hallux rigidus consistently present with progressively worsening first MTPJ pain, swelling, and stiffness. Patients will complain of reduced quality of life due to MTPJ pain-mediated restriction of weight-bearing activities. Stiff shoe insoles, oral and/or topical pain relievers, and even intra-articular corticosteroid injections may have been utilized to temporarily reduce symptoms. Many cases will have a history first MTPJ trauma, with some injuries being surprisingly remote. Patients may have already undergone first MTPJ surgery, albeit unsuccessfully. Lastly, it is not uncommon to have hallux MTPJ deformity and lesser MTPJ transfer pathology coincident with advanced hallux rigidus. Physical exam classically reveals a first MTPJ with obvious (Fig. 8.1) and tender dorsal osteophytes, restricted passive joint motion, most notably in dorsiflexion, and MTPJ pain with hallux weight-bearing during propulsion. Comparison to the contralateral hallux, if unaf-

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sary in the setting of obvious advanced radiographic joint destruction changes. Injections are often utilized during the nonsurgical treatment phase of advanced hallux rigidus. Beyond strengthening the diagnosis, corticosteroid injection also can provide a substantial period of pain relief. Multiple injections are discouraged as thinning of the subdermal fat can sometimes result, and, therefore, complicate future incisional healing.

8.3

Fig. 8.1  Pre-operative photo with dorsal joint prominence due to underlying osteophytes

fected, can be used to quantify the percentage of motion restriction. Commonly, standard weight-bearing foot radiographs are used to assess hallux rigidus. As the degree of joint space narrowing and size and number of periarticular osteophytes increases, so does the condition’s grade/class. Advanced disease is typically defined radiographically as a first MTPJ with osteophytes dorsally, medially, and laterally, involving the sesamoid articulations with moderate to severe joint space loss [1]. Radiographs will reveal evidence of previous surgical intervention and can be used to quantify coincident joint malalignment and deformity. Magnetic resonance imaging (MRI) may be indicated if attempts at cartilage restoration surgery are being considered, but it typically is not neces-

Surgical Technique

The surgery is performed with the patient supine and the heel at the end of the bed. An ipsilateral hip bump is typically utilized. Monitored anesthesia and an ultrasound-guided popliteal regional nerve block together provide pain relief, and a thigh tourniquet provides intraoperative hemostasis. Special equipment to have available includes Hewson suture passers and standard cup and cone reamers used for first MTPJ arthrodesis procedures. Two excellent RTM options include: GRAFTJACKET Matrix (Wright Medical Technology Inc., Memphis, Tennessee, and ArthroFLEX®, Arthrex Inc., Naples, Florida). A standard dorsal approach to the first MTPJ is utilized. The incision is made slightly medial to the extensor hallucis longus (EHL) tendon and centered over the jointline. The interval between the EHL and the dorsomedial neurovascular bundle is identified. Gentle blunt retraction protects both structures, and a capsulotomy is performed in line with the incision. Medial and lateral capsular ligaments are subperiosteally released proximally followed by a thorough joint synovectomy (Fig. 8.2). Despite adequate capsular release, substantial joint stiffness often remains; therefore, a McGlamry elevator is passed plantarly, and through the metatarsal-sesamoid joints, to release adhesions and fibrosed sesamoid suspensory ligaments (Fig. 8.3). The joint exposure is now complete. Periarticular osteophytes are removed with the ultimate goal of achieving a spherical metatarsal head while minimizing metatarsal shortening.

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a

Fig. 8.2  MTPJ has been released yet sustanstial contractures continue to limit exposure, especially in flexion

b

Fig. 8.4 Cheilectomy has been performed and head reamer guidewire has been placed

Fig. 8.3  McGlamery elevator utilized to release the plantar metatarsosesamoid joints and fascilitate full joint mobilization and exposure

Overaggressive cheilectomy is discouraged as bone stock may be necessary for future operations. A standard metatarsal head reamer is ­ideally suited to shape the metatarsal, and it is operated over a carefully placed retrograde intra-

medullary guidewire (Figs. 8.4a, 8.5, and 8.6a). The prepared head is then drilled to improve graft bio-ingrown and incorporation (Fig.  8.6b). If additional joint decompression is needed, a modified Keller proximal phalanx basilar osteotomy could be considered. If utilized, disruption of plantar capsule, flexor hallucis brevis insertions, and plantar plate is avoided by minimizing plantar bone resection during the Keller osteotomy (Fig. 8.7b). Securing the RTM graft to the prepared metatarsal head begins with placement of two vertical drill holes, one medial and one lateral, through the metatarsal and just proximal to the sesamoids (Fig.  8.7b). Absorbable grasping sutures are placed along one side of the graft (Figs.  8.7b and  8.8). Either looped wires (Fig.  8.9a) or Hewson suture passers (Fig. 8.9b) can be utilized

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Fig. 8.5  Reamers are utilized to remove metatarsal head cartilage

a

b

Fig. 8.6  The metatarsal head is drilled to fascilitate graft bio-ingrowth and incorporation

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a

b

Fig. 8.7  Drill holes are placed in the metatarsal neck being sure to remain proximal to the metatarsosesamoid articulations. Shaded region of hallux phalanx in (b) indicates appropriate Keller osteotomy bone resection

to shuttle the grasping sutures under the metatarsal head taking care to orient the “shiny” reticular graft surface to interface with the metatarsal head. Tensioning these sutures draws the graft into the metatarsal-sesamoid joints (Fig.  8.10). Typically, one suture from each side is sutured to the other to secure the graft. The remaining distal graft is now draped dorsally and proximally to cover the metatarsal head. Strategically placed absorbable sutures are placed to pull the graft tightly to the head. Securing to the previously tied suture bridge works well (Figs.  8.11, 8.12, 8.13, and 8.14). Some small “dog-ears” may occur and should be trimmed. Once a snug con-

Fig. 8.8  Grasping sutures are placed through the leading edge of the graft to fascilitate plantar shuttling

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a

b

Fig. 8.9  Looped wires (a) or Hewson suture passers (b) can be utilized to shuttle graft passing sutures from plantar to dorsal throgh the metatarsal neck

8.4

Fig. 8.10  Grasping sutures have been tensioned and graft has been interposed into the metatarsosesamoid joints

toured fit is achieved, passive range-of-motion is checked. If restriction is encountered that was not present prior to graft placement, one of the securing sutures will likely need replaced. Confirm graft stability, and consider suturing the graft to the metatarsal head or adjacent capsule if graft instability is observed. The joint is irrigated and the capsule repaired with 0 caliber absorbable suture. Subdermal tissue is closed with 2-0 absorbable suture and skin with 3-0 nylon suture. A light compressive spica dressing is applied under a protective Jones splint.

Postoperative Care

Please refer to Chap. 1 for a complete description of all postoperative protocols. Patients are discharged home with instructions to remain ­non-­weight-­bearing for the first week. After initial follow-up, 7–10  days postoperatively, progression to full weight-bearing in a removable walking cast is allowed. Compression spica dressings are utilized to minimize swelling that may cause pain and therefore delay joint mobilization exercises. Patients are typically ready to transition to a stiffened shoe by 4  weeks postoperatively. Physical therapy begins at this point and continues 4–6  weeks. Transition to jogging and eventual aggressive activities requiring first MTPJ dorsiflexion and push-off can occur anywhere between 3 and 6 months.

References 1. Coughlin MJ, Shurnas PS.  Hallux rigidus. Grading and long-term results of operative treatment. J Bone Joint Surg Am. 2003;85-A(11):2072–88. 2. Berlet GC, Hyer CF, Lee TH, Philbin TM, Hartman JF, Wright ML. Interpositional arthroplasty of the first

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a

b

Fig. 8.11  Sutures are placed to secure the graft to the dorsal metatarsal head

a

b

c

Fig. 8.12  Further suturing of the graft to the dorsal metatarsal

a

b

Fig. 8.13  Dorsal view of the dorsal graft suturing technique

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a

b

Fig. 8.14  Completed interposition clinical photograph and representative drawing

Intraoperative Pearls/Pitfalls

It is our opinion that a common problem related to this procedure is postoperative stiffness due to overstuffing of the joint. This can be avoided by adequately releasing and decompressing the joint, using the modified Keller osteotomy if necessary, and by performing frequent intraoperative passive ROM assessments. Do not expect ROM to improve postoperatively. In addition, it is felt that postoperative joint malalignment can occur due to poor intraoperative graft control. Suturing the graft to the capsule and into the metatarsal head can help stabilize the graft and avoid this complication. Lastly, it is critical that the graft be completely interposed between the sesamoids and the metatarsal head to avoid postoperative pain production from those joints.

MTP joint using a regenerative tissue matrix for the treatment of advanced hallux rigidus. Foot Ankle Int. 2008;29(1):10–21. 3. Brage ME, Ball ST.  Surgical options for salvage of end-stage hallux rigidus. Foot Ankle Clin. 2002;7(1):49–73. 4. Coughlin MJ, Shurnas PJ. Soft-tissue arthroplasty for hallux rigidus. Foot Ankle Int. 2003;24(9):661–72. 5. Hamilton WG, O’malley MJ, Thompson FM, Kovatis PE, Roger Mann Award 1995. Capsular interposition arthroplasty for severe hallux rigidus. Foot Ankle Int. 1997;18(2):68–70. 6. Johnson JE, Mccormick JJ.  Modified oblique Keller capsular interposition arthroplasty (MOKCIA) for treatment of late-stage hallux rigidus. Foot Ankle Int. 2014;35(4):415–22.

9

First Metatarsal Cheilectomy and Osteochondral Defect Treatments Bryan Van Dyke and Terrence M. Philbin

9.1

Introduction

Degenerative joint disease in the first metatarsophalangeal joint is a progressive disease ultimately leading to end-stage hallux rigidus. We commonly use the Coughlin grading system for hallux rigidus from grade 1 to grade 4 [1]. Bussewitz et  al. showed successful results at 3-year follow-up with cheilectomy for grades 1, 2, and 3 hallux rigidus [2]. More recent attention to treating focal cartilage defects of the first  metatarsal head has also shown excellent results at 3-year follow-up [3]. Identifying and ­intervening earlier in this disease can reduce pain, preserve function, and delay or prevent progression.

9.2

inciting event, but often these symptoms are the result of repetitive microtrauma over time. The patient should be examined for overall range of motion of the first MTP joint as well as pain with motion. A grind test may also be positive. For patients with predominantly plantar pain, sesamoid injury and turf toe injuries should be investigated. If there is any history of an open wound, fevers, chills, erythema, drainage, or warmth, a septic joint should be interrogated further and may require joint aspiration for synovial fluid analysis. Crystalline arthropathy such as gout is also common in the first MTP joint.

9.3

Patient History and Findings

Patients will generally present with the complaint of pain and stiffness in the first metatarsophalangeal joint. They may experience swelling as well. These symptoms are often exacerbated by ­activity. Patients may recall a specific traumatic B. Van Dyke (*) Summit Orthopaedics, Idaho Falls, ID, USA T. M. Philbin Orthopedic Foot & Ankle Center, Worthington, OH, USA

Imaging and Diagnostic Studies

Standard three-view (AP, oblique, lateral) weight-­ bearing radiographs should be obtained of the foot. It is important to obtain weight-bearing films as the overall alignment of the foot may differ from the resting position. The first metatarsophalangeal joint should be evaluated for concentricity of the joint space, joint space narrowing, osteophyte formation, articular defects, and subchondral cysts. These abnormalities may be present on both the metatarsal head and phalanx base. Typically with low-grade hallux rigidus, there will be some joint space narrowing and dorsal metatarsal head osteophytes.

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With standard radiographs we are interpreting the quality of the cartilage based upon the joint space maintained. Focal osteochondral defects may not be apparent, especially if there is no subchondral bone loss. MRI is useful for evaluating the first MTP joint to look at the quality of the articular cartilage, the presence of subchondral cysts, and bone edema.

9.4

Surgical Management

9.4.1 Preoperative Planning Appropriate discussion should be had with patient regarding the progressive nature of joint disease. We always discuss that there is no true cure for arthritis and that it may become worse over time even with surgery. Our short-term goals are pain relief and improved function, but there is likelihood that this disease will progress and may need further treatment in the future. Often we do not fully know the extent of cartilage damage until we are able to visualize the joint intraoperatively. It may be necessary to consent the patient for additional surgery, such as microfracture or cartilage allograft, if there appears to be a lesion intraoperatively that is not amenable to dorsal cheilectomy alone.

9.4.2 Positioning and Equipment We utilize standard supine positioning on the operative room table. Most patients will need a small bump underneath the ipsilateral hip to position the foot vertically. Having the first metatarsal vertical is especially helpful if performing cartilage implantation where gravity can help keep the graft within the defect. We typically use a thigh tourniquet throughout the case.

9.4.3 Approach We use a standard dorsomedial incision centered over the first metatarsophalangeal joint. Care is taken to identify and protect the dorsomedial cutaneous nerve. The extensor hallucis longus

tendon is kept within its sheath. The joint capsule is incised longitudinally dorsomedially in line with the incision. The capsule is elevated and protected for repair at closure. There is typically synovitis within the joint that is debrided with either the scalpel or a rongeur. Small Hohmann retractors are placed medially and laterally, the toe is plantarflexed, and the articular surfaces are inspected. For closure, we repair the capsule with 0 vicryl suture, typically using a figure-8 stitch. If there is some degree of hallux valgus, then the medial capsule can be imbricated and repaired with a pants over vest technique to improve sesamoid alignment. The subcutaneous layer is closed with interrupted 2-0 vicryl, and the skin is closed with a running subcuticular 3-0 monocryl.

9.5

Surgical Techniques

9.5.1 Cheilectomy Typically there are large dorsal osteophytes on both the metatarsal head and the proximal phalanx base. We will expose the joint as described above and evaluate the joint surfaces. Often there is denuded cartilage, especially dorsally. This can be addressed with the dorsal cheilectomy. We will use a microsagittal saw to resect the dorsal portion of the metatarsal head. Up to 33% of the dorsal joint surface may be removed without creating instability [4]. Care is taken to exit along the dorsal aspect of the metatarsal shaft to create a smooth transition. You may need to angle the cut slightly dorsally to avoid notching the dorsal shaft of the metatarsal. The microsagittal saw can be used to remove the corners of the cut as well to avoid prominent edges. The rongeur is used to further remove any prominent bone. The rongeur is used to remove the dorsal osteophytes of the proximal phalanx as well. The toe should be taken through a range of motion to make sure there is smooth motion without impingement. If there is a large medial eminence, it may be resected with the microsagittal saw as well. A  McGlamry elevator can be used to carefully release the sesamoid suspensory ligaments taking care to avoid damaging the cartilage.

9  First Metatarsal Cheilectomy and Osteochondral Defect Treatments

9.5.1.1 Case Example A 45-year-old male presents with left great toe pain for many years. He has a prominent bump on the dorsum of her first metatarsal head. He has pain with dorsiflexion. He has tried shoe modifications, activity restrictions, and NSAIDs and has not obtained relief. He is active in martial arts and is adamant about maintaining first metatarsophalangeal motion. Physical exam is relatively normal except dorsal mass over first metatarsophalangeal joint, positive crepitus, and pain with motion. Range of motion is significantly limited. Radiographs show large dorsal osteophytes from both the metatarsal head and proximal phalanx base. Nonoperative and surgical treatment options were discussed, and he elected to proceed with first metatarsophalangeal cheilectomy. He had an uneventful recovery. He participated in physical therapy. Preoperative and 3-month postoperative radiographs are displayed below. He is doing well and returning to martial arts. A discussion was had regarding eventual definitive treatment in the form of arthrodesis with the hope of 5–10  years of good relief beforehand (Figs. 9.1 and 9.2).

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9.5.2 Subchondral Drilling For focal articular defects, not amenable to removal by dorsal cheilectomy, we perform subchondral drilling for marrow stimulation. The loose or damaged cartilage is removed sharply with a curette or scalpel to create stable cartilage borders circumferentially. The subchondral bone should be examined for integrity. If there is a subchondral cyst, it may need to be filled with cancellous autograft. We will typically harvest this from the calcaneus. For the microfracture, we will perform a subchondral drilling using a 0.062 k-wire with a wire driver to perforate the subchondral plate and stimulate marrow. This is expected to produce fibrocartilage in the area of the defect.

9.5.3 Cartilage Allograft In cases of failed microfracture or unstable lesions with known subchondral cyst, we advocate for allograft cartilage implantation. The implants have reported cartilage formation more similar to hyaline cartilage than the fibrocartilage

Fig. 9.1  Preoperative radiographs of left first metatarsophalangeal joint demonstrating significant dorsal osteophytes of both the metatarsal head and proximal phalanx base

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Fig. 9.2  Three-month postoperative radiographs of left first metatarsophalangeal joint after cheilectomy

typically created by subchondral drilling alone [5]. If you are considering using an allograft implant, you should notify your facility in advance to make sure it is available on the day of surgery. Particulated juvenile articular cartilage (PJAC) is a commercially available product that has given us excellent results [3]. The focal defect is exposed as described previously. Any denuded or loose cartilage is removed to create a circumferential stable border of healthy cartilage. The manufacturer’s guidelines do not recommend performing subchondral drilling in conjunction with PJAC implantation. The surface should be dry. A thin coat of fibrin glue is placed into the defect. The minced cartilage pieces are laid into the defect, and a freer elevator can be used to gently lay the pieces flat. Another thin layer of fibrin glue is placed overtop of the allograft and allowed to dry. The joint is reduced and closed as described above (Fig. 9.3).

9.5.3.1 Case Presentation A 51-year-old female presents with right great toe pain. She complains of pain that is worse with activity, especially running. She has tried rest, ice, NSAIDs, and a Morton’s extension splint.

She has diffuse tenderness in her first metatarsophalangeal joint and pain throughout passive range of motion. Her radiographs demonstrate moderate hallux rigidus. She was actually seen in the office 2 years prior and offered a dorsal cheilectomy, but she decided that she was able to manage her symptoms nonoperatively at that point. Now the pain is much worse, and she is requesting the surgery that was discussed 2 years ago. An MRI was obtained which demonstrated a lateral metatarsal head osteochondral defect reported as 5 × 4 mm full thickness cartilage loss with underlying edema. The options of arthrodesis versus cheilectomy with cartilage allograft were discussed. Despite presenting arthrodesis as the most definitive single surgical treatment, the patient elected for cheilectomy with cartilage allograft. Intraoperatively the dorsal osteophytes were removed with a sagittal saw. The osteochondral defect was located centrally and laterally and was only partially amenable to removal by cheilectomy. After removing loose cartilage flaps, the osteochondral defect measured 10 mm wide and 12  mm tall. The particulated juvenile articular cartilage was applied to the defect (Figs. 9.4, 9.5, and 9.6).

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Fig. 9.3  Focal osteochondral defect of the first metatarsal head after dorsal cheilectomy and defect preparation. Implantation of particulated juvenile articular cartilage allograft with fibrin glue coating

Fig. 9.4  Preoperative standing radiographs AP and lateral demonstrating moderate joint space narrowing with large dorsal osteophyte on the metatarsal head

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Fig. 9.5  Preoperative T2 MRI coronal and sagittal slices demonstrating focal osteochondral defect involving the central and lateral portion of the metatarsal head. There is increased signal in the subchondral bone

Fig. 9.6  Postoperative weight-bearing radiographs demonstrating decompression of the first metatarsophalangeal osteophytes

9  First Metatarsal Cheilectomy and Osteochondral Defect Treatments

Intra-operative Pearls and Pitfalls

• Evaluate and note the range of motion of the first MTP with the patient sedated prior to making an incision. This will help you determine the amount of improvement you have achieved and if additional decompression is necessary. • Educate patient on the progressive nature of hallux rigidus and that even with surgery they may need future treatment, including possible arthrodesis.

9.6

Post-op Care

Patients are placed into a standard well-padded posterior splint and kept non-weight-bearing initially. They follow the OFA Group 1 Protocol: nonweight-bearing splint for 1 week, weight-­bearing as tolerated in a boot for 3 weeks, and then transition to regular shoe wear. Physical therapy is initiated at week 4 as needed to improve range of motion.

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Potential Complications

• Stiffness • Recurrence and/or hallux rigidus progression

References 1. Coughlin MJ, Shurnas PS.  Hallux Rigidus: grading and long-term results of operative treatment. JBJS. 2003;85:2072–88. 2. Bussewitz BW, Dyment MM, Hyer CF. Intermediate-­ term results following first metatarsal cheilectomy. Foot Ankle Spec. 2013;6(3):191–5. 3. Van Dyke B, Berlet GC, Daigre JL, Hyer CF, Philbin TM. First metatarsal head osteochondral defect treatment with particulated juvenile cartilage allograft transplantation: a case series. FAI. 2018;39(2):236–41. 4. Coughlin MJ, Shurnas PS.  Hallux Rigidus: surgical techniques (cheilectomy and arthrodesis). JBJS. 2004;86(suppl 1, pt 2):119–30. 5. Farr J, Tabet SK, Margerrison E, Cole BJ.  Clinical, radiographic, and histological outcomes after cartilage repair with particulated juvenile articular cartilage: a 2-year prospective study. Am J Sports Med. 2014;42(6):1417–25.

10

Neuroma Travis Langan, Adam Halverson, and David Goss Jr.

10.1 Introduction The third web space is the most common (66%) location for an interdigital neuroma. In 21% of patients, neuromas are present bilaterality [4]. The pathogenesis is thought to be nerve entrapment due to repetitive compressive trauma of plantar nerve against transverse intermetatarsal ligament [5, 8]. A neuroma is actually best described as perineural fibrosis in most instances rather than a true neuroma, as a true neuroma shows irregular histologic nerve tissue proliferation [3]. What is commonly referred to as a primary interdigital neuroma usually histologically shows signs of nerve degeneration, including degeneration of myelinated fibers, thickening of the epineurium and perineurium, thickening and hyalinization of the walls of the neural vessels, and concentric edema within the nerve [2, 3, 11].

10.2 Patient Presentation A thorough patient history and physical examination are always performed. Patients frequently complain of burning pain in the plantar forefoot or a sensation of fullness between the metatarsal T. Langan (*) · A. Halverson · D. Goss Jr. Orthopedic Foot and Ankle Center, Orthopedic Foot and Ankle Surgery, Worthington, OH, USA e-mail: [email protected]

heads. Some patients may say they feel like they are “walking on a pebble” or “balled-up sock.” There is often radiation of pain or tingling into the corresponding toes. Frequently, narrow shoes and high heels intensify symptoms. Patients will often massage the area when describing the location of their discomfort. Some patients may report a recent increase or change in activity level. It is imperative with digital and forefoot-­ driven pathology to assess patients in a loaded and unloaded position. The authors recommend evaluating the patient as they cycle through a normal gait and assess the patient in a non-weight-­ bearing position. As with most forefoot issues, assessing the gastrocnemius and soleus muscle complex for tightness is crucial. A standard Silfverskiold test is performed to assess for gastroc-­soleal equinus. Clinically, one can often palpate a firmness or fullness between the associated metatarsal heads (Fig. 10.1). This can be a chronic and fibrotic feeling or acute and boggy. Typically, the metatarsal heads themselves are non-painful. Pain will be associated with squeezing the intermetatarsal space from dorsal to plantar (Fig. 10.2). Pain may worsen when the toes are dorsiflexed. Side-to-­side compression of the metatarsal heads (Fig.  10.3) will reduce the space between metatarsal heads and can produce the a palpable and/or audible click (Mulder’s sign) [9]. This test has sensitivity of 94–98% [6, 10]. The pain and nerve sensations will be localized to the affected web space and toes.

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Fig. 10.1  Palpating the intermetatarsal space

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It is important to differentiate between neuroma pain and other potential pathologies. Most commonly, clinicians will differentiate between Morton’s neuroma and metatarsophalangeal (MTP) joint pathologies. Evaluate for joint pain, MTP joint instability, and/or metatarsal pain. If there is pain while manipulating the joint, pressing directly on the metatarsal head or base of the proximal phalanx, or while palpating the metatarsal, the pain is likely not due to a neuroma, and the patient should be worked up for metatarsal or plantar plate injury. Always remember though, there may be concomitant pathologies present.

10.3 D  iagnostic and Imaging Work-Up

Fig. 10.2  Palpating the intermetatarsal space dorsal to plantar

Fig. 10.3  Side-to-side compression of the metatarsal heads

Upon initial examination, a standard series of three weight-bearing foot radiographs are taken. These images primarily serve to rule out any structural cause of symptoms that could mimic neuroma. Differential diagnoses that can be observed radiographically include bone and soft tissue malignancy, other space-occupying lesions, metatarsophalangeal arthritis, Freiberg’s disease, stress fracture, toe deformity, and metatarsophalangeal instability. Advanced imaging used for diagnosis of Morton’s neuroma includes ultrasound and MRI. MRI has a reported sensitivity of 93% and specificity of 68% [13]. Ultrasound sensitivity was found to be 90% with specificity of 88% [13]. Availability of quality ultrasound can vary by institution. While clinical diagnosis remains the gold standard for diagnosis of Morton’s neuroma, MRI is often employed in our practice prior to surgical intervention to ensure no other space-­ occupying lesions are contributing. It is also beneficial at assessing other web spaces and ruling out stress fracture and Freiberg’s disease. Injection also plays a key diagnostic role. It is usually performed if patients are refractory to initial non-operative modalities including topical nonsteroidal anti-inflammatory drug (NSAID) and shoe modification. Injection can simply involve local anesthetic for diagnostic purposes, but we typically include corticosteroids to add some durable therapeutic benefit. Injections are

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ceiling. For a plantar approach, the surgeon may elect to have the patient in a prone position. Typically, general anesthesia and preoperative popliteal and saphenous blocks are utilized during this type of case. A thigh tourniquet is applied to the patient’s operative limb, and the limb is prepped and draped in the usual standard fashion.

10.6 Operative Technique: Key Operative Steps Fig. 10.4  Injection 1–2 cm proximal to metatarsal heads from dorsal approach

generally performed from a dorsal approach 1–2  cm proximal to the metatarsal heads (Fig. 10.4). Repeat injections are used judiciously to avoid complications such as local tissue atrophy and ligamentous laxity. We find most patients who get relief but have recurrent symptoms are eventually treated surgically.

10.4 Non-operative Treatment Conservative treatments consist of orthoses with offloading metatarsal pads, shoe gear modification, anti-inflammatories, and physical therapy. Injections of corticosteroid can be utilized with some success. The authors strictly avoid sclerosing alcohol injections. In our experience, alcohol injections generally have little success and can even result in worsening symptoms. When conservative treatments fail, operative intervention is considered. Up to 80% of cases will eventually require surgical resection [7].

10.5 O  R Setup and Instrumentation and Hardware Recommendation Patients are typically on the operating room table in a supine position. A bump is placed under the patient’s ipsilateral hip until the patella faces the

10.6.1 Dorsal Approach Neurectomy Most patients with first time neuroma excision are treated with dorsal approach in our practice. This incision allows for a more rapid recovery and more proximal visualization. The incision is longitudinal and placed in the dorsal recess between metatarsal heads, working proximally (Fig.  10.5). Dissection is carried through skin and any bleeders are cauterized. The dorsal intermetatarsal ligament is identified (Fig.  10.6) and transected sharply (Fig.  10.7). A self-retaining retractor or small lamina spreader is gently placed between metatarsal necks and is used to improve visualization. Careful dissection is performed to identify the nerve (Fig.  10.8). Digital palpation externally at the distal interspace can allow the neuroma to protrude distal to the deep transverse metatarsal ligament, and probing with freer elevator is used to locate the bulbous plantar nerve. The deep transverse metatarsal ligament is incised to visualize the neuroma fully. Dissection continues along the nerve distally into the base of each toe. The associated digital branches are isolated and each transected sharply with a fresh blade. Care is then taken to ensure the nerve and its branches are dissected as proximal as possible into the plantar intrinsic musculature. At the discretion of the surgeon, prior to transecting the proximal aspect of the neuroma, an epineural injection of corticosteroid can be considered. Distal traction is applied to the nerve and transected sharply as proximal as possible allowing the residual nerve to retract into the intrinsic muscles. The nerve should be

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Fig. 10.6  Identification of the deep transverse intermetatarsal ligament

Fig. 10.5  Dorsal incisional placement for a second intermetatarsal neuroma

resected at least 3 cm proximal to the proximal edge of the transverse metatarsal ligament. This is done to avoid tethering of the nerve stump and allow the nerve stump to be off the weight-­ bearing surface [1]. Some surgeons will send the transected nerve (Fig.  10.9) for pathological specimen. The tourniquet is deflated to achieve proper hemostasis as a hematoma in the site can cause complications postoperatively. The site is irrigated and layered closure is performed.

10.6.2 Plantar Approach for Revision Neurectomy The patient may be placed supine or prone for this approach; however, the authors will routinely

Fig. 10.7  Following transection of the deep transverse intermetatarsal ligament

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Fig. 10.10  Plantar incisional approach Fig. 10.8  Identification and dissection of the plantar interdigital nerve

Fig. 10.9  Resected nerve tissue and its branches

do this approach with the patient supine. The bed is elevated to a comfortable level with the surgeon seated at the foot of the bed. The limb is prepped and draped in the usual standard fashion, and a thigh tourniquet is elevated after limb exsanguination. A 3–4 cm incision is made longitudinally over the patients’ preoperatively determined point of tenderness (Fig. 10.10). This is done in the intermetatarsal space staring at the metatarsal heads and working proximally. Alternatively, a horizontal incision can be utilized; however, our preferred approach is longitudinal. The longitudinal incision can have a curvilinear or lazy S shape to

prevent longitudinal scar contraction. Dissection is carried down through the plantar fat, and venous bleeders are coagulated (Fig. 10.11). The metatarsal heads are used as a reference for the appropriate trajectory as the dissection is carried deeper. The plantar aponeurosis is exposed, and Weitlaner retractor is used to retain the surrounding plantar fat for visualization. The plantar aponeurosis is then incised longitudinally with a No.15 blade, and tenotomy scissors are used to dissect out the nerve proximally and trace it distally to the neuroma stump (Fig. 10.12). Unlike the dorsal approach, the intermetatarsal ligament should not need to be transected as this lies dorsal to the nerve. Once identified, the digital nerve is gently pulled distally into the wound and clamped with a hemostat (Fig. 10.13). Dissection ­continues distally to identify its digital branches. It is then transected proximally and distally (Fig.  10.14). After transection the ankle can be fully dorsiflexed to facilitate further retraction of the nerve into the midfoot. Some surgeons will use a hemostat on the nerve to transplant it deep into the plantar musculature (Fig. 10.15). The wound is then irrigated and the tourniquet deflated to obtain hemostasis and prevent

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Fig. 10.11  Plantar fat pad dissection

Fig. 10.12  Dissection and identification of the nerve

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Fig. 10.13  Nerve is pulled distal and clamped with hemostat

Fig. 10.14  The nerve is transected proximally and distally with the stump clamped in the hemostat

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and the patient is encouraged to heel weight bear in a protective boot until the sutures are ready for removal. Sutures are then removed based on patient’s healing potential and when the incisions have healed appropriately. At week 4, the patients are transitioned back into a fully weightbearing shoe. Physical therapy is rarely needed but initiated as necessary to aid in range of motion and gait. A main focus of physical therapy is to prevent painful scar or scar contractures. Recurrent neuromas may need a more conservative postoperative protocol. These patients may need a longer non-weight-bearing period and more aggressive soft tissue massage. Patients are appropriately followed for 6 to 12  months for close monitoring of improved functional outcome measures.

Pearls, Pitfalls, and Resident Resource Fig. 10.15  The nerve stump is transpositioned into the deep musculature

h­ ematoma formation. The wound is then closed in a layered fashion. Of note, at the surgeon’s discretion, some extra considerations may be utilized in recurrent neuroma surgery. Transposition of the nerve stump into the adjacent plantar foot muscle belly has been used with success, and some recommend epineural injection or bathing the nerve stump with corticosteroid prior to closure to avoid excess inflammation [11, 12].

10.7 Postoperative Protocol This surgery falls into postoperative protocol #1. The standard dressing applied to the operative limb is a sterile well-padded Jones compression dressing with posterior splint. For a primary dorsal approach, the authors recommend a period of non-weight-bearing approximately 7 to 10 days and then transitioning the patient to a pneumatic walking boot with protected weight-bearing until week 4. For plantar approach surgeries, the patient is non-weight-bearing for 7 to 10  days,

• Conservative treatments consist of orthoses with metatarsal pads, modification of shoe gear, anti-inflammatories, and corticosteroid injections. • Dorsal incision is generally used in primary cases and plantar incision generally reserved for revision cases. • Careful dissection of the nerve is key for proper resection. • Hemostasis is important for prevention of hematoma. • A period of non-weight-bearing is used early, followed by a period of protected weight-bearing until the incision heals. • In recurrent surgeries, consider transposition of the nerve stump into the adjacent muscle belly and adding corticosteroid intraoperatively.

References 1. Amis JA, Siverhus SW, Liwnicz BH.  An anatomic basis for recurrence after Morton’s neuroma excision. Foot Ankle. 1992;13(3):153–6. 2. Giannini S, Bacchini P, Ceccarelli F, Vannini F. Interdigital neuroma: clinical examination and histopathologic results in 63 cases treated with ­excision.

108 Foot Ankle Int. 2004;25(2):79–84. https://doi. org/10.1177/107110070402500208. 3. Johnson JE, Johnson KA, Unni KK.  Persistent pain after excision of an interdigital neuroma. Results of reoperation. J Bone Joint Surg Am. 1988;70(5):651–7. 4. Kasparek M, Schneider W.  Surgical treatment of Morton’s neuroma: clinical results after open excision. Int Orthop. 2013;37(9):1857–61. https://doi. org/10.1007/s00264-013-2002-6. 5. Lee M-J, Kim S, Huh Y-M, et  al. Morton neuroma: evaluated with ultrasonography and MR imaging. Korean J Radiol. 2007;8(2):148–55. https://doi. org/10.3348/kjr.2007.8.2.148. 6. Mahadevan D, Venkatesan M, Bhatt R, Bhatia M.  Diagnostic accuracy of clinical tests for Morton’s neuroma compared with ultrasonography. J Foot Ankle Surg. 2015;54(4):549–53. https://doi. org/10.1053/j.jfas.2014.09.021. 7. Mann RA, Reynolds JC.  Interdigital neuroma–a critical clinical analysis. Foot Ankle. 1983;3(4):238–43.

T. Langan et al. 8. Morscher E, Ulrich J, Dick W. Morton’s intermetatarsal neuroma: morphology and histological substrate. Foot Ankle Int. 2000;21(7):558–62. 9. Mulder JD.  The causative mechanism in morton’s metatarsalgia. J Bone Joint Surg Br. 1951;33-B(1):94–5. 10. Pastides P, El-Sallakh S, Charalambides C. Morton’s neuroma: a clinical versus radiological diagnosis. Foot Ankle Surg. 2012;18(1):22–4. https://doi. org/10.1016/j.fas.2011.01.007. 11. Richardson DR, Dean EM. The recurrent Morton neuroma: what now? Foot Ankle Clin. 2014;19(3):437– 49. https://doi.org/10.1016/j.fcl.2014.06.006. 12. Wolfort SF, Dellon AL.  Treatment of recurrent neuroma of the interdigital nerve by implantation of the proximal nerve into muscle in the arch of the foot. J Foot Ankle Surg. 2001;40(6):404–10. 13. Xu Z, Duan X, Yu X, Wang H, Dong X, Xiang Z. The accuracy of ultrasonography and magnetic resonance imaging for the diagnosis of Morton’s neuroma: a systematic review. Clin Radiol. 2015;70(4):351–8. https://doi.org/10.1016/j.crad.2014.10.017.

Turf Toe and Sesamoid Injuries

11

Matthew M. Buchanan

11.1 Introduction Injuries to the capsuloligamentous structures of the 1st metatarsophalangeal (MTP) joint were first described by Ryan in 1975 [1] and named “turf toe” by Bowers and Martin in 1976 [2]. This term generally includes injury occurring to the capsular, ligamentous, and osseous structures of the 1st MTP joint. Originally, this injury was described in football players and attributed to the increased traction afforded by the new artificial turf playing fields in combination with a lightweight, flexible shoe. Turf toe injuries are debilitating sports injuries because the hallux is pivotal to an athlete’s ability to accelerate and cut [3]. These injuries are occurring with increasing frequency at all levels of competition [4]. The osseous structures of the 1st MTP joint include the shallow concave base of the proximal phalanx articulating with the convex head of the first metatarsal. Due to the lack of significant bony congruity, this is an inherently unstable joint. Joint stability is improved by the capsular and ligamentous structures connecting the metatarsal head to the base of the proximal phalanx. The first layer of soft tissue support comes from the fibrous MTP joint capsule. The plantar

M. M. Buchanan (*) Center for Sports Medicine and Orthopaedics, Chattanooga, TN, USA

plate is a thickening of this capsule on the plantar surface of the 1st MTP joint and has a firm attachment on the proximal phalanx and a weaker attachment on the metatarsal head [5]. Next, ligament support provides additional stability to the MTP joint. These ligaments include the broad medial and lateral collateral ligaments, medial and lateral metatarsal-sesamoid ligaments, and transverse intermetatarsal ligament. The intrinsic tendons inserting into the base of the proximal phalanx provide additional support medially (abductor hallucis), laterally (adductor hallucis), and plantarly (flexor hallucis brevis). The sesamoid bones are embedded within the FHB tendon and are connected by a thick intersesamoid ligament that makes up the central component of the plantar plate of the first MTP joint [6, 7] (Fig. 11.1). The 1st MTP joint typically supports more than 50% of bodyweight with normal weight-­ bearing, 200–300% with athletics, and increases to 800% with jumping [8–11]. The sesamoid bones articulate with the plantar surface of the 1st metatarsal and withstand tremendous forces as a result of their location. The medial and lateral sesamoid bones provide a number of advantages to the function of the great toe. The sesamoid bones serve to elevate the 1st metatarsal head, improving the biomechanical advantage of the FHB and FHL tendons. With weight-bearing, the medial and lateral sesamoid bones provide protection to the FHL tendon, which runs between

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110 Fig. 11.1  Anatomy of the plantar aspect of the 1st MTP joint. (Modified image from Richard D. Ferkel)

Lateral phalangeosesamoid ligament Lateral metatarsosesamoid ligament Lateral sesamoid

Flexor hallucis longus tendon

Medial phalangeosesamoid ligament Medial metatarsosesamoid ligament Medial sesamoid

Adductor hallucis: Transverse Oblique

Intersesamoid ligament Flexor hallucis brevis: Lateral head Medial head

these two bones. Additionally, the dorsal surface of each sesamoid bone is covered in cartilage, articulating with the plantar surface of the metatarsal head. This joint surface reduces friction of the FHB tendons as they pass plantar to the 1st MTP joint. The enormous forces encountered by this part of the foot can lead to a variety of injuries ranging from acute rupture of the plantar soft tissues to chronic overuse injuries. In the acute setting, patients will often describe a mechanism that includes axial loading of the 1st MTP joint while in a forced dorsiflexion position. This specific injury mechanism can lead to complete rupture of the plantar plate with proximal sesamoid retraction, partial rupture of the plantar plate without instability, acute sesamoid fractures, diastasis of bipartite sesamoids, and metatarsal head impaction injuries. The tear in the plantar plate typically occurs on the proximal phalanx

side of the 1st MTP joint but also has been described from the 1st metatarsal head. Chronic overuse injuries result from repetitive stress applied to the plantar surface of the forefoot as seen in high-impact running and jumping sports and occupations where standing and walking are prevalent. Excessive stress applied to the sesamoids over a prolonged period of time leads to a spectrum of pathology starting with sesamoiditis and progressing to sesamoid stress fractures and ultimately avascular necrosis (AVN). Chronic overuse syndromes involve the medial sesamoid bone more often than the lateral sesamoid bone due to the larger size of the medial sesamoid and increased forces that it supports during weight-bearing. Certain biomechanical factors (achilles contracture and pes cavus) and improper footwear (high heels and shoes lacking sufficient protection/support) may predispose patients to plantar forefoot overload syndromes.

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11.2 Clinical Case Examples 11.2.1 Case Example #1: Medial Sesamoid Excision and Repair of Torn Medial Collateral Ligament Twenty-two-year-old male 2 years after a motorcycle accident with 1st MTP medial collateral ligament injury and chronic ununited medial sesamoid fracture. Failed 2  years of conservative treatment including boot, post-op shoe, custom orthotics, sesamoid off-loading pads, carbon fiber plantar plate, shoe changes, and activity modification. Patient describes development of hallux valgus deformity and pain over medial sesamoid with push-off (Figs. 11.2, 11.3, 11.4, 11.5, 11.6, 11.7, 11.8, 11.9, 11.10, 11.11, 11.12, 11.13, 11.14, and 11.15).

Fig. 11.3 Sagittal MRI view with chronic ununited medial sesamoid fracture

Fig. 11.4  Axial MRI scan showing medial collateral ligament injury and intra-articular damage

Fig. 11.2  Chronic ununited medial sesamoid fracture with subtle hallux valgus deformity

Fig. 11.5  Preoperative assessment

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Fig. 11.6  Medial approach between dorsomedial and plantar medial cutaneous nerve branches

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Fig. 11.9  Excised medial sesamoid with cartilage loss and fragmentation of proximal fragment

Fig. 11.7 Capsular exposure from 12 o’clock to 6 o’clock with retraction of cutaneous nerves and visualization of abductor hallucis tendon

Fig. 11.10  Medial eminence removal with distal metatarsal osteotomy utilizing longer dorsal arm

Fig. 11.8  L-shaped capsulotomy with visualization of medial sesamoid

Fig. 11.11  Lateral shift neutralizing valgus forces and bi-cortical screw fixation

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Fig. 11.12  Multiple interrupted sutures repairing FHB tendon and advancing abductor hallucis into defect

Fig. 11.13  Capsular repair and advancement of abductor hallucis tendon

Fig. 11.15  Weight-bearing AP x-ray at 1st post-­operative visit

11.2.2 Case Example #2: Plantar Plate Repair Through L-shaped Extensile Plantar Approach

Fig. 11.14  Repeat examination

simulated

weight-bearing

Intraoperative photographs demonstrate the skin incision and exposure of the plantar 1st MTP joint made possible through an L-shaped extensile plantar approach (Figs. 11.16 and 11.17).

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repetitive loading of the plantar forefoot (distance running, dancing, rock climbing). They may have occupations that require frequent use of stairs or ladders. A thorough history often reveals an increase in the amount of force applied to the sesamoids as seen with runners who switch to lighter shoes and adopt a “forefoot-loading” running style. Prolonged use of high-heeled shoes can also lead to sesamoid overload syndromes.

Fig. 11.16  L-shaped plantar incision

Fig. 11.17 Exposure of the plantar plate and FHL tendon

11.3 Presentation In the acute setting, patients will describe a hyperextension injury followed by pain and swelling of the 1st MTP joint. Walking will be difficult if not impossible. Varying degrees of ecchymosis on both the dorsal and plantar aspects of the foot will be present. Symptoms may localize to the plantar surface of the 1st MTP joint although a more severe injury creates dorsal impaction fractures of the 1st MT head. Patients may describe hearing a “pop” at the time of injury. In the chronic setting, patients often describe involvement in sports or activities that require

11.4 Diagnosis Inspection of the foot in the acute setting will include assessment of the resting posture of the toe (hyperextension may occur with a loss of the static plantar stabilizers) and the location and degree of edema, erythema, and ecchymosis. Carefully palpate the medial and lateral MTP joint line, each sesamoid bone, and the plantar plate. Assess the degree of dorsal 1st MTP joint tenderness as severe dorsiflexion of the phalanx on the 1st metatarsal can cause metatarsal head impaction fractures. Look for signs of lesser MTP joint injuries. Patients may have an antalgic gait or could be completely unable to ambulate on the ball of the injured foot. Chronic injuries will tolerate a more focused physical exam. Weight-bearing inspection may reveal varus/valgus malalignment or pronation/ supination deformities. Palpate both the medial and lateral sesamoid bones. Assess the stability of the MTP joint to varus/valgus stress testing and drawer examinations. Compare the full active and passive range of motion of the great toe to the contralateral side. Perform a gait analysis looking for antalgic patterns such as toe walking or diminished stance phase on the symptomatic side.

11.5 Imaging Radiologic imaging of the foot includes weight-­ bearing anteroposterior, oblique, and lateral foot x-rays. Bilateral AP foot weight-bearing views may be required to assess normal sesamoid position (Fig.  11.18). Lateral foot x-rays can

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Fig. 11.20  Dorsiflexion lateral foot XR showing lack of distal sesamoid migration with dorsiflexion, consistent with complete plantar plate rupture

Fig. 11.18  Bilateral AP foot x-ray with left diastatic bipartite medial sesamoid and proximal retraction of the lateral sesamoid

Fig. 11.21  Sagittal MRI view showing complete plantar plate rupture

Fig. 11.19  Lateral foot XR shows plantar plate rupture with increased distance from sesamoid to proximal phalanx

reveal proximal retraction of the sesamoids (Fig.  11.19), and forced dorsiflexion lateral views assess the integrity of the plantar plate/ sesamoid complex (Fig.  11.20). Finally, axial sesamoid views provide a unique look at the sesamoids and their position on the plantar surface of the metatarsal head. Fluoroscopic evaluation includes all the previously described x-ray techniques but adds the ability to perform a dynamic assessment of the

stability of the sesamoid complex. With active dorsiflexion, an immobile sesamoid on the plantar aspect of the 1st metatarsal confirms an unstable injury to the sesamoid complex. Magnetic resonance imaging (MRI) provides the unequaled ability to thoroughly evaluate the degree of both bone and soft tissue pathology. MRI evaluates the integrity of the plantar plate, presence of chondral injuries, and the condition of the surrounding osseous structures (stress injuries and dorsal impaction fractures). MRI may show a complete plantar plate rupture (Fig. 11.21) or an acute sesamoid fracture (Fig. 11.22). Computed tomography (CT) is another helpful modality, particularly when highly detailed evaluation of bony anatomy is indicated. CT scans pick up on subtle avulsion fractures and

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Fig. 11.22  Sagittal MRI shows acute sesamoid fracture with gapping at the fracture site

help differentiate acute from chronic injuries. Newer weight-bearing CT scans may reveal foot alignment abnormalities that contribute to chronic sesamoid overload syndromes.

11.6 OR Setup Three approaches are commonly used to treat turf toe and sesamoid injuries: medial, dorsolateral, and direct plantar. A medial approach will use a smaller hip bump to maintain some external rotation of the lower limb. A dorsolateral approach will use a larger hip bump to internally rotate the leg, improving exposure of the 1st web space. For a direct plantar approach, the patient is positioned supine with a bump under the ­ipsilateral hip to point the toes toward the ceiling. The use of the bone foam ramp (https://www. bonefoam.com/product/positioners/the-ramppositioner/) elevates the operative leg above the contralateral leg. This elevation facilitates surgical exposure and improves the ease of intraoperative fluoroscopic imaging. Hemostasis is performed with Esmarch exsanguination and inflation of a tourniquet. A surgical assistant holds the leg during the case to optimize patient positioning, notably ankle dorsiflexion during plantar surgical approaches. Instrumentation necessary for surgery will depend on the type of approach utilized and the pathology encountered. In addition to a complete foot tray, specialty instruments available to the surgeon should include sharp Weitlander retractors, Gelpi retractors, small single-action rongeurs, battery drill and small drill bits, Inge

lamina spreaders, small pin-type joint distractors, bone reduction forceps, and specialty scalpel blades (Beaver blades). The surgeon should also have a variety of nonabsorbable sutures available to perform end-to-end ligament repair. Specialty suture passing instruments (Suture Lasso and Mini Scorpion (Arthrex, Inc. Naples, FL)) may be useful to pass sutures in areas that are difficult to access [12]. Additionally, small suture anchors may be needed to reattach avulsed ligament to the bone. If the anatomy does not support the use of suture anchors, sutures can be passed through bone tunnels and tied on the opposite side. This will require the use of small suture passers.

11.7 Operative Technique A complete understanding of the turf toe and sesamoid pathology guides the surgeon’s choice of available surgical approaches (medial, dorsolateral, and/or plantar). The surgical plan may involve direct repair of the plantar plate involving end-to-end suture repair or reattachment with suture anchors, partial or complete medial and/or lateral sesamoid excision, medial collateral ligament repair, flexor hallucis brevis repair, abductor hallucis advancement, MTP joint debridement with marrow stimulation, and/or cartilage repair techniques and collateral ligament repair/ stabilization.

11.8 Medial Approach The medial approach to the 1st MTP joint optimizes exposure for medial sesamoid fracture excision and/or medial collateral ligament repair. It opens the interval between the dorsomedial cutaneous nerve (distal branch of the superficial peroneal nerve) and plantar medial cutaneous nerve (distal branch of medial plantar nerve). The medial capsule is exposed from dorsal (12 o’clock) to plantar (6 o’clock). Careful evaluation and inspection of the medial capsule reveals the extent of any medial collateral ligament rupture.

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Once the medial approach has been completed, thorough inspection of local soft tissues is performed. Capsulotomy may not be necessary in the acute setting as the traumatic ligament rupture may afford exposure of the 1st MTP joint and medial sesamoid. Chronic injuries may require a formal capsulotomy. Capsulotomy techniques vary, but the author prefers an L-shaped capsulotomy as it offers an extensile approach to the joint. The vertical limb is in line with the joint surface and extends plantarly down to the medial sesamoid. The horizontal limb is parallel to the mid-shaft of the metatarsal. The L-shaped flap is retracted, creating excellent visualization of the sesamoid sling and MTP joint. This approach allows direct repair of medial collateral ligament injury and facilitates advancement of the abductor hallucis tendon during medial sesamoid excision [13].

11.9 Dorsolateral Approach A dorsolateral approach is the authors’ preferred approach for a lateral sesamoid excision [14]. This approach avoids a plantar incision through exposure of the dorsal aspect of the first web space. An Inge lamina spreader serves to spread the 1st and 2nd metatarsals, optimizing surgical exposure. Long-handled tenotomy scissors facilitate a deeper dissection. If a lateral collateral ligament injury is encountered, a TightRope (Arthrex, Inc. Naples, FL) or alternative suture-button construct may assist in collateral ligament repair. The dorsolateral approach is utilized most often for lateral sesamoid excisions. Once the approach is performed, care is taken to avoid injury to the common digital nerve below the intermetatarsal ligament [14]. A Beaver blade is used to make an incision through the intersesamoid ligament on the medial side of the fibular sesamoid. This allows lateral retraction of the sesamoid while preventing retraction of the fibular sesamoid under the metatarsal head [14]. Care is taken to avoid injury to the FHL tendon. Plantarflexion of the MTP joint relaxes

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tension on the plantar soft tissues. Following excision, the adductor tendon and FHB are advanced into the defect using multiple interrupted sutures.

11.10 Plantar Approach For plantar approaches, the surgeon has the choice of an L-shaped extensile incision (Fig. 11.16) or a two-incision (medial and lateral) surgical technique. The two-incision approach allows improved visualization of the lateral aspect of the plantar plate [8]. A plantar approach is the preferred technique to address a complete plantar plate rupture with proximal retraction of the sesamoids. Either technique requires careful exposure and protection of the plantar medial digital nerve (medial exposure) and the common plantar digital nerve (lateral exposure) [5]. If a dorsal joint-impaction injury is present, a combined dorsal and plantar approach will be necessary to address all involved pathology. A small pin-type joint distractor may be necessary to distract the joint in order to evaluate and treat intra-­ articular injuries. Once the plantar approach has been completed, the extent of the tear is determined. If a mid-substance tear is present, multiple interrupted sutures may be passed to reapproximate the torn tissue. If the plantar plate ruptures off the base of the proximal phalanx, the plantar plate is repaired to the proximal phalanx through the use of suture anchors or bone tunnels. The base of the proximal phalanx is “roughened” using a small single-action rongeur. This technique produces a bleeding bony bed ideal for ligamentous healing [12]. Locking sutures are placed in the plantar plate and advanced through drill holes passed from plantar to dorsal. A separate dorsal incision is utilized to mobilize the EHL during tying of the sutures. Typically, three drill holes are utilized with two separate sutures passing through the central tunnel and one each on the medial and lateral tunnels. Knots are tied on the medial and lateral aspect of the EHL tendon with the toe held in a plantarflexed position.

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The dorsolateral approach to the lateral sesamoid allows for complete excision of the lateral Upon completion of the procedure, patients are sesamoid while avoiding a plantar incision. placed in a well-padded posterior splint position- Fragmentation of the sesamoid can be avoided by ing the toe in a gentle plantarflexed position. careful “shelling out” of the sesamoid utilizing Patients are instructed to limit weight-bearing by sharp Beaver blade scalpels. Avoid excessive the use of a wheelchair and/or knee scooter. traction on the sesamoid with rongeurs or Kocher Patients are encouraged to elevate “toes to nose” clamps. One or two sutures placed in the lateral for 50  minutes of each hour during the initial soft tissues allow lateral retraction during incision of the intersesamoid ligament, the “key 2 weeks after surgery. At 2 weeks post-op, sutures are removed and move” of this procedure [14]. With plantar approaches for plantar plate patients may progress to heel weight-bearing in a bootwalker. Boot may be removed when sitting repairs, the surgeon should have available a and sleeping, and a gentle passive range-of-­ ­number of minimally invasive suture placing and motion program is initiated, avoiding excessive suture passing instruments to allow repair of deep stress on the repair site. If tissue quality is com- structures that can be difficult to access. promised or patient compliance is a concern, a Depending on the chronicity of the injury, careful fiberglass cast with foot plate extending past the mobilization of the plantar plate will allow reattachment to the base of the proximal phalanx. toes may be considered. At 6  weeks post-op, formal physical therapy Direct repair of the plantar plate to the base of the begins with a goal of restoring full joint strength proximal phalanx requires the use of small drills and range of motion. With the guidance of the and suture passers as well as a dorsal approach to physical therapist, patients may wean from the tie down the repair sutures. Alternatively, small suture anchors can be utilized to secure the planboot into a stiff postoperative surgical shoe. At 10  weeks post-op, patients transition into tar plate to the proximal phalanx. Patients are educated that any surgical intersupportive athletic or hiking shoes with wide toe vention involves the risk of infection and injury box and/or carbon fiber plates. to arteries and nerves. Complications specific to this surgery include painful plantar scars, re-­ rupture of repaired ligaments, recurrence of the Pearls and Pitfalls preoperative deformity, cartilage damage from When utilizing the medial approach to acute joint trauma, and development of chronic repair torn medial collateral ligaments or pain. Patients should be educated that they may resect a diseased sesamoid, the surgeon not return to their pre-injury level of function. must ensure that the forces affecting the 1st Nonsurgical treatment of plantar plate and MTP joint have been balanced upon comsesamoid injuries to the 1st MTP joint may also pletion of the procedure. The surgeon be associated with complications. These complishould be prepared to release the adductor cations could include failure of the injury to heal tendon or perform a realignment osteotwith non-operative treatment, chronic joint instaomy. Advancement of the abductor tendon bility, re-rupture of injured ligaments, progresinto the defect created by medial sesamoid sive toe alignment abnormalities, and cartilage excision helps to prevent a postoperative damage from the initial joint trauma. If left hallux valgus deformity [13]. Careful preuntreated, an unstable injury to the plantar plate operative imaging including weight-bearcomplex develops into a hallux claw deformity ing x-rays will assist with intraoperative with MTP joint extension, IP joint flexion, and decision-making. MTP joint dislocation (Figs. 11.23 and 11.24).

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References

Fig. 11.23 AP foot x-ray of neglected plantar plate rupture

Fig. 11.24  Lateral foot x-ray of neglected plantar plate rupture

1. Ryan AJ, et al. Artificial turf: pros and cons (round-­ table). Physician Sports Med. 1975;3:41–50. 2. Bowers KD, Martin RB.  Turf-toe: a shoe-surface related football injury. Med Sci Sports Exerc. 1976;8:81–3. 3. Frimenko RE, Lievers W, Coughlin MJ, Anderson RB, Crandall JR, Kent RW. Etiology and biomechanics of first metatarsophalangeal joint sprains (turf toe) in athletes. Crit Rev Biomed Eng. 2012;40:43–61. 4. Anderson RB, Hunt KJ, McCormick JJ. Management of common sports-related injuries about the foot and ankle. J Am Acad Orthop Surg. 2010;18(9):546–56. 5. McCormick JJ, Anderson RB.  Surgical correction of the recalcitrant turf toe. Tech Foot Ankle Surg. 2013;12:29–38. 6. Dedmond BT, et al. The hallucal sesamoid complex. J Am Acad Orthop Surg. 2006;14:745–53. 7. Richardson EG. Injuries to the hallucal sesamoids in the athlete. Foot Ankle. 1987;7:229–44. 8. McCormick JJ, Anderson RB.  The great toe: failed turf toe, chronic turf toe, and complicated sesamoid injuries. Foot Ankle Clin. 2009;14:135–50. 9. Nigg BM.  Biomechanical aspects of running. In: Nigg BM, editor. Biomechanics of running shoes. Champaign: Human Kinetics Publishers; 1986. p. 1–25. 10. Nigg BM, Yeardon MR.  Biomechanical aspects of playing surfaces. J Sports Sci. 1987;5:117–45. 11. Stokes IA, Hutton WC, Stott JR, et al. Forces under the hallux valgus foot before and after surgery. Clin Orthop Relat Res. 1979;142:64–72. 12. Doty JF, Coughlin MJ.  Turf toe repair: a technical note. Foot Ankle Spec. 2013;6(6):452–6. 13. Anderson RB.  Turf toe injuries of the hallux metatarsophalangeal joint. Tech Foot Ankle Surg. 2002;1(2):102–11. 14. Kurian J, McCall DA, Ferkel RD. Dorsolateral excision of the fibular sesamoid: techniques and results. Tech Foot Ankle Surg. 2014;13(4):226–33.

Tarsometatarsal Joint Arthrodesis

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Mark A. Prissel and Jeffrey E. McAlister

Tarsometatarsal (TMT) joint arthrodesis is performed for a variety of etiologies including primary midfoot osteoarthritis, post-traumatic arthritis, complex multiplanar foot deformity, neuromuscular disease, and Charcot neuroarthropathy. Several of these etiologies and their associated management are covered in alternate pertinent chapters. The main focus of this chapter will be TMT arthrodesis related to primary osteoarthritis, post-traumatic arthritis, and some discussion regarding the procedures as they relate to associated foot deformities. TMT arthrodesis can be considered for an isolated, affected ray (i.e., 1st, 2nd, or 3rd), or for multiple adjacent rays. Preoperative considerations often include initial conservative strategies including supportive shoe gear, rocker bottom shoe gear, altered lacing patterns, custom-molded orthoses, NSAIDS, topical medications, and immobilization. Imaging is paramount to understanding the associated deformities present and extent of arthritic change present in the affected joint segments. Standard

M. A. Prissel (*) Orthopedic Foot & Ankle Center, Worthington, OH, USA e-mail: [email protected] J. E. McAlister Arcadia Orthopedics and Sports Medicine, Phoenix, AZ, USA

weight-bearing foot and ankle radiographs are performed. The AP foot radiograph is important to assess transverse plane (i.e., adduction/ abduction)-associated deformities. The oblique foot radiograph provides the best visualization of the TMT joint lines and is the best initial assessment of the extent of arthritic change present. The lateral foot radiograph is helpful to assess for plantar gapping and longitudinal collapse, which is often present in more advanced cases, as well as evaluation of the overall foot structure for arch type. The lateral radiographic also provides excellent visualization of the dorsal osteophytosis and bossing that frequently coincides with advancing arthrosis. Advanced imaging is helpful for preoperative planning. Most commonly MRI is utilized prior to surgery to understand the extent of cartilage loss and specific joint segment involvement. In cases of more severe deformity, additional imaging can be utilized including CT with or without 3-D reconstruction. Injection therapy with fluoroscopic guidance can also be a useful adjunct therapy providing useful diagnostic information and temporizing therapeutic relief. When an injection is performed in the small joints of the midfoot, we recommend fluoroscopic guidance to confirm the specific location, to help guide surgical planning based on extent of patient relief. Use of contrast dye for the guided injection can be a helpful tool, but is at the discretion of the surgeon.

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12.1 Indications

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verified on both an AP and oblique view. Upon making the incision, care is taken to avoid and appropriately retract the dorsal neurovascular • Primary TMT osteoarthritis structures (Fig. 12.1a, b). An interval is identified • Post-traumatic arthritis to deepen the dissection to the level of the joint of • Complex multiplanar foot deformity interest. Weitlaner retraction is most efficient • Neuromuscular disease once dissection is deepened. The appropriate joint • Charcot neuroarthropathy is identified and a transverse capsulotomy is performed (Fig. 12.1c). As a reminder, the 2nd TMT is relatively more proximal (as the “keystone”) 12.2 Operating Room Setup than the adjacent 1st or 3rd TMT joints. The patient is positioned on the operative table in Verification of the correct joint is paramount prior the supine position. We recommend general anes- to moving forward with the procedure. A ronguer thesia with an ipsilateral popliteal/saphenous is utilized to excise all dorsal hypertrophy. At this nerve block. Following onset of appropriate anes- point the joint borders should be well defined. A thesia, a thigh tourniquet is applied. A hip bump Hintermann distractor is placed from the metataris placed, neutralizing any external rotation of the sal to the proximal extent of associated cuneiform hip. The extremity is prepped to the tourniquet (Fig. 12.1d). Care is taken not to place the distracand draped with exposure of the operative limb tor too close the TMT joint surface, to prevent cut out into the joint, which can compromise fixation including the knee. Power equipment is available and utilize options. Cartilaginous surfaces are denuded with including corded electric sagittal saw and power hand instrumentation including curettes, ronguer, rasp. Cordless drivers are utilized to aid in main- and 1/4 inch curved osteotome (Fig. 12.1e). Once tenance of efficiency and limit the frequency of all cartilage is removed, the exposed subchondral plate is fenestrated with a solid core drill (2.0– equipment exchanges. A mini-fluoroscopy unit is draped and posi- 2.5  mm), and the surfaces are then fish-scaled tioned on the same side of the table as the opera- with an osteotome to complete the preparation of tive limb. The back table is positioned opposite the subchondral plate (Fig. 12.1f, g). Often, calcathe fluoroscopy unit and operative limb. All neal autograft is procured prior to debridement of required hardware and associated instrumenta- the joint and mixed with bone marrow aspirate. tion is available and ready for use. Additional Following the joint preparation, the bone graft case-specific instrumentation includes an AO and BMA are placed within the fusion site. The quick connect 7 mm bone harvester, Hintermann-­ Hintermann retractor is removed. Provisional fixation is applied. The authors preferred construct is type retractor, curettes, and osteotomes. to initially place a 4.0 mm screw and dorsal-based compression staple. The guide wire for the cannulated screw is placed initially as the provisional 12.3 Isolated TMT Arthrodesis fixation from the lateral metatarsal base into the A linear, longitudinal incision is planned over the associated cuneiform. Care is taken to appropriappropriate interval. Care is taken to not inappro- ately drop one’s hand to ensure the proper trajecpriately place the incision. Most commonly the tory of the screw, which should be nearly parallel error is to estimate too medial for the location of to the ground to avoid suboptimal placement in the joint of interest. Topographic anatomy can be the cuneiform (i.e., too plantar). Fluoroscopic utilized to aid in positioning; the 3rd toe longi- verification of intended trajectory is obtained. The tudinally lines up with the 2nd TMT, and the 4th appropriate length screw is then inserted. A toe longitudinally lines up with the 3rd headed or headless screw can be considered at the TMT.  Fluoroscopic confirmation can be utilized surgeon’s discretion. Supplemental dorsal comto confirm appropriate position and should be pression staple is then placed in standard fashion

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Fig. 12.1 (a) Incision is approximately 3  cm in length centered over the TMT. (b) Incision is approximately 3 cm in length centered over the TMT. (c) The incision is taken down to the joint capsule. The joint capsulotomy is performed and periosteum elevated with an elevator. (d) A pin-to-pin joint distractor is utilized to allow for joint visualization and preparation for arthrodesis. (e) A proper

joint preparation is key to this procedure with elevation of the cartilage with an osteotome and curette. (f) A solid 2–3 mm drill is then utilized to fenestrate the subchondral bone on both surfaces of the joint. (g) A small straight osteotomy is then utilized to “fish scale” the joint surfaces as well

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e

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g

Fig. 12.1 (continued)

in line with the long axis of the foot. The screw fixation is relatively oblique to the staple. An alternate fixation construct is an anatomically contoured single-column TMT plate employing an eccentric drilling technique to provide compression (Fig. 12.2a, b). Closure is obtained of the subcutaneous layer and skin by the surgeon’s preferred method.

12.4 C  ombined First and Second TMT Arthrodesis Either a single incisional approach or dual incisional approach can be considered for this combined arthrodesis. If a single incision is selected, a longitudinal linear or curvilinear incision is planned over the lateral extent of the 1st TMT. If

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and BMA are utilized as well in this instance. Often, the authors will include preparation of the intercuneiform joint (medial/intermediate) in the fusion construct essentially creating a “four corner fusion” of the medial column. Once appropriate preparation of the involved joint segments is completed, provisional fixation is inserted and position is verified fluoroscopically. The joint segments are provisionally stabilized with guide wires for 4.0 mm cannulated screws. The typical construct for the compression screws is a medial cuneiform to 2nd metatarsal base screw (i.e., Lisfranc screw, 1C–2M), an intercuneiform screw (1C–2C), and a 1st metatarsal to intermediate cuneiform screw (1M–2C). Once the appropriate length screws are placed, supplemental fixation is applied with a locking plate construct to the dorsal medial 1st TMT joint and a dorsal compression staple to the 2nd TMT joint (Fig. 12.3a, b). An alternate fixation construct is an anatomically contoured 1st & 2nd TM-specific locking plate with eccentric drilling ability (Fig. 12.3c, d). Closure is obtained of the subcutaneous layer and skin by the surgeon’s preferred method.

12.5 C  ombined Second and Third TMT Arthrodesis

Fig. 12.2 (a, b) Isolated 2nd TMT/LisFranc injury with a comminuted 2nd MT base which was bridge plated with allograft

a dual incisional approach is preferred, a medial linear incision is planned about the 1st TMT, and a dorsal linear incision is approximated over the lateral extent of the 2nd TMT taking care to maintain a skin bridge of at least 3 cm. The incisions are deepened and structures are protected identical to the description above. The proper joint segments are confirmed fluoroscopically. The involved joints are prepped in standard fashion as described above. Bone autografting

A dorsal linear or curvilinear is recommended for this combined arthrodesis. The incision is planned over the lateral extent of the 2nd TMT or over the 3rd TMT. The most common error is to too medially estimate the appropriate incisional location. Position should be verified fluoroscopically. The incision(s) are deepened and structures are protected identical to the description above. The proper joint segments are confirmed fluoroscopically. The involved joints are prepped in standard fashion as described above. Bone autografting and BMA are utilized as well in this instance. Often, the authors will include preparation of the intercuneiform joint (intermediate/lateral). Once appropriate preparation of the involved joint segments is completed, provisional fixation is

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a

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Fig. 12.3 (a, b) Postoperative weight-bearing AP (A) and lateral (B) radiographs demonstrating 1st & 2nd TMT fusion with described construct. (c, d) Postoperative

weight-bearing AP (A) and lateral (B) radiographs demonstrating plate fixation for 1st & 2nd TMT fusion with modified construct

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inserted and position is verified fluoroscopically. The joint segments are provisionally stabilized with guide wires for 4.0 mm cannulated screws. The typical construct for the compression screws is similar to the isolated TMT screw fixation from the lateral base of each involved metatarsal to the associated cuneiform, for both the 2nd and 3rd TMT joints. Once the screw fixation is placed, supplementary dorsal compression staple fixation is applied to each TMT. At the proximal extent of a

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the cuneiforms a third staple can be utilized in a transverse orientation to compress and stabilize the intercuneiform space. Alternate fixation constructs can be considered, including a dual ray anatomically contour joint-specific 2nd and 3rd TMT plate or a single-column TMT anatomically contoured plate for each the 2nd and 3rd TMT.  Closure is obtained of the subcutaneous layer and skin by the surgeon’s preferred method (Figs. 12.4a–g and 12.5a–f). b

c

Fig. 12.4 (a, b) Preoperative AP (A) and lateral (B) foot radiograph demonstrating significant 2nd & 3rd TMT arthritis. (c) Hintermann retractor based distraction for joint preparation. (d) Cannulated screw headless fixation for the 2nd and 3rd TMT joints providing compression to

the plantar half of the fusion surfaces. (e) Final fixation construct with headless screw fixation and dorsal staple for the 2nd and 3rd TMT joints. (f, g) Mature fusion of 2nd and 3rd TMT arthrodesis

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Fig. 12.4 (continued)

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Fig. 12.5  Preoperative radiographic imaging of neglected subtle Lisfranc injury with 2nd and 3rd metatarsal base fractures with AP (a), close up oblique (b), and lateral (c).

Postoperative AP (d), oblique (e), and lateral (f) radiographic imaging of primary fusion for neglected subtle Lisfranc injury, sparing the 1st TMT articulation

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d

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Fig. 12.5 (continued)

e

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12.6 Multiple TMT Fusion with Wedge Resection For instances of more complex deformity (e.g., neglected Lisfranc fracture/dislocation), a multiple TMT fusion (1st, 2nd, 3rd TMT) with wedge resection can be considered. A dual incisional approach is preferred for this technique with a linear medial incision about the 1st TMT and a linear dorsal incision over the 3rd TMT.  Preoperative deformity correction planning is helpful for this technique to understand the apex, extent, and multiplanar orientation of the deformity. In this application more extensive dissection is often required taking care to expose the dorsal surface of the TMT joints between the incisions protecting the anterior neurovascular bundle throughout. An Army-Navy retractor or ribbon retractor should be able to be placed between the incisions protecting the dorsal skin and soft tissues prior to execution of the wedge resection. Once the incisions have been verified, completed, and the dissection is deepened to expose the involved joints, K-wires can be placed as cut guide references for the joint resection. Fluoroscopic position of the intended resection is verified orthogonally. The wedge resection is typically performed with an appropriately sized sagittal saw maintaining proper retraction of the dorsal and plantar soft tissues. Alternatively, the resection can be performed with osteotomes. In the instance of significant concomitant frontal plane deformity, the resection can be extended laterally across the cuboid to make a through-­and-­through osteotomy to aid in derotation. The 4th and 5th TMT joint should be maintained whenever possible. Once the osteotomy is completed, the wedge is excised and joint preparation is completed as noted above. Often supplemental preparation of the

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intercuneiform spaces is performed to provide further stability to the construct. The joint surfaces are bone grafted, as described above. Provisional fixation is applied with guide wires for the 4.0 mm screws. The position of the fixation is dependent on the specific deformity present, but often some combination of longitudinal (e.g., 1M–1C) and oblique (e.g., 1C–2M) is required. Supplemental fixation is then applied most commonly with a medially based locking plate construct to the 1st TMT and dorsal fixation across the 2nd and 3rd TMT joints with either compression staples or anatomically contoured locking plates. Closure is obtained of the subcutaneous layer and skin by the surgeon’s preferred method (Figs. 12.6a–e and 12.7a–g).

12.7 Postoperative Management The patient is placed into a well-padded posterior splint. They are clinically evaluated at 7–10 days postoperative and converted to short-leg casting at that time. Casting is continued and changed at 3-week intervals for 6 weeks (i.e., cast change at 4  weeks postoperative). At 7  weeks postoperative, consideration is made for weight bearing to tolerance in a pneumatic walking boot versus weight-bearing cast. Interval radiographs are obtained at each visit to monitor interval osseous integration, maintenance of correction, and hardware positioning. Physical therapy is typically initiated at 8 weeks postoperative, so long as bone healing is appropriate and the patient is no longer cast immobilized. By 10 weeks the patient is transitioned into a supportive ankle brace and stiff-­ soled shoe gear. Once postoperative edema has resolved, the patient is fit for custom-molded orthoses.

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Fig. 12.6  Preoperative AP (a) and lateral (b) demonstrating TMT arthritis. Postoperative weight-bearing AP (c), oblique (d), and lateral (e) radiographs following multiple TMT (1–3) arthrodesis via plate fixation constructs

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Fig. 12.7 Preoperative AP (a) and lateral (b) weight-­ bearing radiographs demonstrating severe TMT arthritis and deformity from chronic, untreated Lisfranc injury. Steinman pin placement placed as cut guide for wedge resection osteotomy (c). Intraoperative imaging demonstrating wire

placement for wedge osteotomy resection (d), sagittal saw wedge excision (e), and pre-reduction wedge excision (f). Postoperative AP (f) and lateral (g) radiographs demonstrating stable union and restoration of the medial arch via wedge resection multiple TMT fusion

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d

f

e

g

Fig. 12.7 (continued)

12  Tarsometatarsal Joint Arthrodesis

12.8 Complications • • • • • •

Postoperative infection Incisional dehiscence/delayed skin healing Sensory nerve injury/neuropraxia Injury to the anterior neurovascular structures Nonunion Painful or prominent hardware

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Pearls

• Initial incisional planning is paramount to successful procedural execution. • Calcaneal autograft and bone marrow aspirate aid in excellent fusion surface apposition. • Low-profile fixation is preferred as the dorsal soft tissue envelope is minimal. • Include intercuneiform fixation to provide more robust arthrodesis constructs.

Cotton Osteotomy

13

Jeffrey S. Weber

13.1 Patient History and Findings

13.2 Clinical Case Example

The Cotton osteotomy is a medial cuneiform dorsal opening wedge osteotomy which is utilized in the treatment of the collapsing pes planovalgus foot type, metatarsus primus elevatus deformity, the overcorrected clubfoot, and forefoot varus deformity. The procedure addresses sagittal plane deformity, allowing the surgeon to plantarflex the medial column. The Cotton osteotomy is most commonly performed as an adjunct procedure to hindfoot reconstruction for congenital or adult-acquired pes planovalgus. In stage II posterior tibial tendon dysfunction (PTTD), the hindfoot progressively falls into valgus and the forefoot and, at times, will compensate by rotating into varus. In stage II, the deformity remains flexible, and reconstructive procedures focus on joint-sparing osteotomies of the calcaneus in conjunction with a flexor digitorum longus (FDL) tendon transfer with either debridement or repair of the posterior tibial tendon. The decision to perform the Cotton osteotomy is reserved for after all hindfoot procedures have been performed and a residual forefoot varus persists.

A 41-year-old female with no significant medical comorbidities presents with the chief complaint of “fallen arches” for several years. She is now experiencing pain along the course of the posterior tibial tendon and within the sinus tarsi. She was referred to the senior author from another podiatric surgeon in the area who had tried both over-the-counter and custom orthotics. Clinical exam revealed a flexible pes planus deformity with ankle equinus contracture. Radiographic views were consistent with adult-acquired flatfoot (Fig.  13.1a, b). MRI confirmed chronic thickening of the posterior tibial tendon with tenosynovitis, inflammation within the sinus tarsi, and no evidence of degenerative joint disease or tarsal coalition. Surgical intervention included a lateral column lengthening, medial calcaneal displacement osteotomy, Cotton osteotomy, gastrocnemius recession, posterior tibial tendon debridement/synovectomy, and FDL tendon transfer to the navicular bone (Fig. 13.1c, d).

J. S. Weber (*) Birch Tree Foot and Ankle Specialists, Traverse City, MI, USA

13.3 Imaging and Diagnostic Studies Weight-bearing radiographs of the foot and ankle are obtained to assess the degree of deformity (Figs. 13.2a, b, 13.3a, b, and 13.4a). In the patient with adult-acquired flatfoot, ankle films are uti-

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a

c

b

d

Fig. 13.1 (a) Preoperative AP radiograph of a 41-year-­ (c) Postoperative AP radiograph of a 41-year-old female old female with stage II PTTD. (b) Preoperative lateral with stage II PTTD. (d) Postoperative lateral radiograph radiograph of a 41-year-old female with stage II PTTD. of a 41-year-old female with stage II PTTD

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a

c

b

d

Fig. 13.2 (a) Lateral radiograph of a 50-year-old female with stage II PTTD. Note the elevated 1st ray deformity. (b) AP radiograph of a 50-year-old female with stage II PTTD. Note the increased amount of talar head uncovering. (c) Postoperative lateral radiograph with allograft

Cotton wedge with staple fixation. A Z-cut calcaneal osteotomy was used to correct transverse and frontal plane deformity. (d) Postoperative AP radiograph with allograft Cotton wedge with staple fixation

lized to assess for the possibility of stage IV or ankle valgus deformity in which the deltoid ligament has become attenuated [1]. A calcaneal axial view is also obtained to assess the degree of hindfoot valgus and may also aid in the diagnosis

of a tarsal coalition if there is obliquity between the middle and posterior facets of the subtalar joint. The lateral foot radiograph may show an elevated first ray when compared to the lesser rays. A loss of congruency of the dorsal cortices

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a

c

b

d

Fig. 13.3 (a) A 54-year-old obese female with stage II PTTD. (b) AP radiograph of the same patient. Note the increased talar head uncovering. (c) Postoperative lateral radiograph showing complete incorporation of the

allograft 11 months post-op. (d) Postoperative AP radiograph status post-subtalar and talonavicular arthrodesis with Cotton wedge allograft

of the first tarsometatarsal joint with plantar gapping is suggestive of instability of this joint. In this case, along with the clinical finding of a hypermobile first ray, a first tarsometatarsal joint arthrodesis is favored to address the instability of the medial column as opposed to the Cotton osteotomy. Arthritic changes in the hindfoot or

medial column joints will also favor arthrodesis as opposed to the Cotton osteotomy. Advanced imaging studies such as MRI and CT scan will give insight into any subtle arthritic changes within medial column joints that are not seen on plain films. Arthritic changes, as stated before, would then favor a plantarflexory arthrodesis

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a

of either the first tarsometatarsal or naviculocuneiform joint (Fig. 13.5a–d). Differential corticosteroid injections into these joints utilizing live fluoroscopy may also aid in surgical decision-making.

b

13.4 Surgical Management 13.4.1 Preoperative Planning

c

Oftentimes, the decision to perform the Cotton osteotomy is reserved for after hindfoot correction has been obtained and a forefoot varus persists when the hindfoot is held in neutral position. Surgical consent for reconstruction of the pes planovalgus deformity often notes the possibility of the Cotton osteotomy, and the patient is educated on the possibility of this prior to surgery. The proper equipment for the procedure is made readily available on the day of surgery.

13.4.2 Positioning and Equipment If a medial calcaneal displacement osteotomy (MCDO) or lateral column lengthening osteotomy (Evans osteotomy) is to be performed prior to the Cotton osteotomy, the patient is placed first in the lateral decubitus position for the initial part of the case. Upon completion of one or both calcaneal osteotomies, the patient remains draped, and the operating room staff assist in repositioning the patient into the supine position to address the posterior tibial tendon pathology and any residual forefoot supinatus deformity.

Fig. 13.4 (a) Preoperative lateral radiograph of patient with stage II PTTD. (b, c) Postoperative AP and lateral radiograph status post Z-cut calcaneal osteotomy, FDL transfer, PT tendon debridement, and Cotton osteotomy

Equipment • Sagittal saw with 9 mm saw blade • Cotton wedge options –– Allograft • Bone • Metallic –– Autograft • Fixation options –– Staple –– Two-hole locking plate –– Wedge plate

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a

c

b d

Fig. 13.5 (a–d) A naviculocuneiform fusion was performed in conjunction with a Z-cut calcaneal osteotomy, flexor digitorum longus tendon transfer, and posterior tibial tendon tenotomy

13  Cotton Osteotomy

There are many commercially available Cotton osteotomy wedge plates, as well as titanium and pre-contoured allograft spacers. Each system varies in graft material and fixation construct, and most have trials which are helpful in sizing in order to obtain the desired amount of correction. Cotton-specific opening wedge plates of varying sizes allow for internal fixation with the option of packing the osteotomy site with cancellous bone autograft, allograft, or other readily available demineralized bone matrix products. Some surgeons have shown excellent correction of forefoot varus with Cotton allograft wedges without the use of internal fixation [2]. The author typically employs the use of either an allograft fixated with a two-hole locking plate, a Nitinol staple, or a

a

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metallic wedge allograft that accommodates its own internal fixation with one or two stabilizing screws that purchase both the graft and medial cuneiform (Figs. 13.2c–d, 13.3c–d, and 13.4b–c).

13.4.3 Approach Incision planning is typically performed with the use of intraoperative fluoroscopy and a freer elevator to identify the central location of the medial cuneiform on an AP foot view (Fig. 13.6a–c). A skin marker is then used to draw a “cross-shaped” mark in the center of the cuneiform (Fig. 13.7a–d). The naviculocuneiform joint and first metatarsocuneiform joint boundaries may also be marked

b

c

Fig. 13.6 (a–c) A freer elevator or k wire is used with fluoroscopy to mark incision placement on the skin. A lateral radiograph with a line drawn medially on the foot aids in directing the sagittal saw during the osteotomy

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a

b

c

d

Fig. 13.7 (a–d) Skin markings are made to outline incision placement and direction of the sagittal saw

to aid in sagittal saw placement when performing the osteotomy. The incision, typically 3–4 cm in length, is carried out in a longitudinal fashion just medial to the extensor hallucis longus (EHL) tendon which is retracted laterally with a self-­ retaining retractor (Fig.  13.8a, b). A periosteal incision is then made parallel with the skin incision, and a periosteal elevator is used to free the periosteum medially and laterally in the central portion of the medial cuneiform. Care is taken to avoid any excess stripping of the periosteal blood supply to the bone.

13.4.4 Technique(s) A 9 mm microsagittal saw blade is held perpendicular to the dorsal cortex of the cuneiform bone, and a lateral radiograph confirms this position in the central portion of the bone (Fig. 13.9a–c). A unicortical osteotomy is then performed from medial to lateral with small sweeping passes of the blade to ensure not to violate the plantar cortex of the medial cuneiform or the medial c­ ortex of the intermediate cuneiform. A heart-shaped distractor is inserted

a

b

Fig. 13.8 (a, b) Dissection is carried down medial to the EHL tendon which is retracted laterally

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Fig. 13.9 (a–c) Fluoroscopy aids in proper placement of the osteotomy cut and to ensure the plantar cortex is left intact

into the osteotomy and distracted several millimeters to accommodate the smallest trial allograft sizer (Fig.  13.10a, b). The sizer is inserted and the subtalar joint is held in its neutral position (Fig. 13.11a–c). The fifth metatarsal head is loaded manually with the surgeon’s hand locking the calcaneocuboid joint, and the residual amount of forefoot varus can be assessed. Sequential trial sizers are inserted until the appropriate amount of correction is achieved. Typical graft size is 5–6 mm. The trial sizer is removed, and the heart-shaped distractor is inserted and slightly over-distracted to allow for ease of insertion of the allograft wedge. Fixation of choice is then performed (Fig. 13.12a–h). AP and lateral radiographs are taken to ensure proper graft placement and fixation have been achieved. Layered closure is performed with 2–0 Vicryl for subcutaneous tissue and 3–0 Nylon for the skin in horizontal mattress fashion.

Intraoperative Pearls and Pitfalls

• Intraoperative fluoroscopy aids in incision placement. The osteotomy will typically fall 2  mm proximal to the second tarsometatarsal joint which is used as a landmark [3]. The incision tends to be more lateral than would be initially assumed. • Avoid extensive periosteal dissection to maintain blood supply, and avoid transecting the dorsal ligaments that stabilize the naviculocuneiform joint (NCJ) and 1st TMT joints. • A set of baby Hohmann retractors is very helpful in identifying the medial and lateral margins of the cuneiform to aid in the osteotomy. • High union rates with allograft wedges limit donor site morbidity of autograft wedges.

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• If the plantar cortex of the medial cuneiform is violated, the graft stability will become compromised. In this situation a two-hole locking plate is recommended for fixation to stabilize the medial cuneiform. • Oversizing the graft may lead to a rigid forefoot valgus. Take care to assess the amount of correction needed with trial sizers to obtain the proper amount of correction.

a

a

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Fig. 13.10 (a, b) The heart-shaped distractor is inserted into the osteotomy and distracted to accommodate the trial size Cotton wedge

Fig. 13.11 (a–c) Trial wedges are inserted until the appropriate size is determined. The trial is removed and the distractor left in place to aid in the insertion of the allograft

13  Cotton Osteotomy

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Fig. 13.12 (a–h) The Cotton metal wedge is inserted. Fluoroscopy confirms the position of the graft which is then fixated with a staple

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h

Fig. 13.12 (continued)

13.5 Postoperative Care • Please refer to Chap. 1 for postoperative protocols for this procedure.

13.6 Potential Complications • Graft subsidence and loss of correction are rare with cadaveric allograft but may occur. The use of titanium Cotton wedges decreases

this risk. Over-distracting the osteotomy before allograft insertion also reduces the need to tamp the graft into place and thus reducing graft collapse. Also, thoroughly rehydrating allograft bone makes it less brittle and less prone to fragmentation. • Graft dislocation is also rare and may be avoided with the use of internal fixation. • Graft nonunion may occur and may require revision. The author routinely soaks allograft in bone marrow aspirate drawn from the patient’s calcaneus at the beginning of the procedure to decrease the incidence of nonunion.

References 1. Bluman EM, Myerson MS.  Posterior tibial tendon rupture: a refined classification system. Foot Ankle Clin. 2007;12(2):233–49. 2. Myerson MS, et  al. Tendon transfer combined with calcaneal osteotomy for treatment of posterior tibial tendon insufficiency: a radiological investigation. Foot Ankle Int. 1995;16(11):712–8. 3. Yarmel D, Mote G, Treaster A. The cotton osteotomy: a technical guide. J Foot Ankle Surg. 2009;48(4): 506–12.

Fourth and Fifth Tarsometatarsal Degenerative Joint Disease Management

14

Maria Romano McGann, Bryan Van Dyke, and Gregory C. Berlet

Arthritis in the fourth and fifth tarsometatarsal (TMT) joints is an uncommon but challenging problem to treat. As the mobile portion of the lateral column of the foot, the 4th and 5th TMT joints are responsible for forefoot accommodation to uneven ground during ambulation. The lateral column normally experiences about 10° degrees of motion in both the flexion-extension and pronation-supination planes [2]. There is reluctance to fuse this area due to unpredictable results [4–6]. A 4th and 5th TMT resection arthroplasty and tendon interposition is an excellent technique for lateral column pain in active patients with significant arthritis in these joints [3].

14.1 Case Presentation Case 1  A 40-year-old female with a remote history of a foot injury where she sustained a lisfranc fracture and underwent ORIF.  Pain in her foot has progressively gotten worse and is now

M. R. McGann (*) Romano Orthopaedic Center, Oak Park, IL, USA B. Van Dyke Summit Orthopaedics, Idaho Falls, ID, USA G. C. Berlet Orthopedic Foot & Ankle Center, Worthington, OH, USA

located on the lateral aspect of her foot. On physical exam, there are calluses present on the lateral aspect of her foot. Weight-bearing x-rays of her foot demonstrate significant joint space narrowing and sclerosis along the 4th and 5th TMT joints. Case 2  A 55-year-old female with history of rheumatoid arthritis presents with pain on the lateral aspect of her foot worse in the morning and after standing/walking for long periods of time. On exam the patient is tender laterally and had pain with motion of her 4th and 5th toes. Radiographs demonstrate significant joint collapse of the 4th and 5th TMT joints. Corticosteroid injections to these joints have provided symptomatic pain relief in the past, however, only give her a few hours of relief currently.

14.2 Presentation Arthrosis along the lateral column of the foot in the 4th and 5th tarsometatarsal (TMT) joints is rare yet problematic in the young, active patients. Patients will present with pain on the lateral aspect of their foot. There may be calluses present on the bottom of their feet due to uneven ground loading of the forefoot. A remote history of a lisfranc injury may be present, where an undiagnosed injury to the lateral

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column likely occurred. Patients may also have a history of inflammatory arthropathy. There also may have been an isolated “nutcracker” injury where the 4th and 5th metatarsals forcefully abduct compressing the cuboid against the calcaneus. Surgical options for these patients include interpositional arthroplasty and arthrodesis. Raikin and Schon reported on arthrodesis for lateral column arthrosis in severe TMT arthritis which can help with pain relief as a joint obliteration technique [1]. This is only indicated in the situation of profound instability such severe lisfranc fracture/dislocation or Charcot arthropathy. Otherwise, arthrodesis in an active patient is not tolerated well, and it creates a stiff lateral column that cannot accommodate the ground. Interpositional arthroplasty of the 4th and 5th TMT joints has been described with several different techniques. Berlet and Anderson published good results utilizing primarily the peroneus tertius tendon [3]. This technique utilizes nearby autogenous tissue and showed little postoperative collapse of the joint space. Pain improved on average 35% and average AOFAS scores were 64.5 at over 2 years. Allograft interposition with commercially available products such as regenerative tissue matrix has been described in other joints, and we have had success with this for the 4th and 5th TMTs as well [7]. Another described technique utilizes a spherical ceramic implant for the interposition [8]. A burr is used to create a hemispherical recess in the opposing joint surfaces. Typically an 11 mm ceramic sphere is utilized as the final implant. They advocate that this procedure is simpler to perform than tendon interposition and still provides the benefits of preserved motion compared to arthrodesis. In recent years at our institution, soft tissue interposition with allograft is most commonly performed.

14.3 Imaging and Diagnostic Studies The standard radiographs that should be obtained are three weight-bearing views of the foot, including an AP, lateral, and oblique view. The oblique view may allow the physician to best evaluate the 4th and 5th TMT joints. Differential injections may also be useful to localize which joints are causing the most pain for patients. To ensure exact placement of the injections, fluoroscopy is used. Radiopaque dye is utilized in the injection to confirm intra-articular placement. Pain diaries can be given to patients for 1 week to document response to the injection. A positive response to the differential injection is prognostic for the amount of pain relief expected with a surgical intervention. Preferred Technique  Soft Tissue Interpositional Arthoplasty for 4th and 5th TMT Joints

14.4 OR Setup Preoperative planning is imperative for the patient. Active patients with stable, arthritic joints are excellent candidates for this procedure. Position the patient at the foot of the bed with a bump on the ipsilateral hip. Preoperative popliteal block helps with postoperative pain control. The equipment required include: 1. Weitlaner self-retainer 2. Hintermann retractor 3. Mini fluoro 4. Drill 5. 1/4 inch curved osteotome 6. Allograft implant if not performing tendon interposition 7. Pineapple burr

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Procedure 1. Exsanguinate limb and inflate the tourniquet. 2. A dorsal lateral incision paralleling the long axis of the foot centered on over 4th metatarsocuboid joint. (a) Take care to avoid the sural nerve. (b) Full-thickness skin flaps are created, and peroneus tertius and EDL of 4th toe are exposed. 3. For tendon interposition: (c) Peroneus tertius or 4th extensor longus can be utilized. Release peroneus tertius tendon proximally and retract it out of the wound. (Use 4th EDL when peroneus tertius is absent.) 4. Perform a dorsal capsulotomy over 4th and 5th TMT joints. 5. Debride the joint, with care to maintain plantar and medial ligaments as well as lateral capsule for support. Consider creating a recess to accommodate the ball shape of the graft. 6. Debride the joint down to subchondral bone of MTs to create 1  cm space in proximal-­ distal direction. 7. For tendon interposition, roll up tendon into “anchovy” and place across the joint in neutral position in coronal and pronation/supination planes. If using allograft, implant may be secured within joint by using 0-vicryl suture through the plantar capsule. 8. 0.062 K wire from distal-lateral to proximal-­ medial through interpositional tissue to help further secure it in place. 9. If possible, close capsule dorsally with absorbable suture. 10. Routine skin closure and well-padded posterior splint applied with ankle in neutral position.

14.5 P  ost-Op Care (See Protocol Chapter) (d) NWB 6–8  weeks in splint, then pull pins. Once pins are removed, may begin WBAT. (e) Slow recovery over a year with x-rays that continue to appear as arthritis. The x-ray appearance should not be too disconcerting as the clinical picture often is asymmetric to the x-ray appearance.

Intraoperative Pearls and Pitfalls

• It is important to preserve the lateral capsule between the 5th metatarsal and the cuboid that acts as a collateral ligament stabilizer of the lateral column TMT joints. • Take care to insure the interpositional material stays secured with joint during closure. A free-floating graft, regardless of the material type, will tend to create a foreign body-like reaction and associated swelling.

14.6 Potential Complications • Sural nerve injury • Persistent pain; may address with arthrodesis in severe cases

References 1. Raikin SM, Schon LC. Arthrodesis of the fourth and fifth tarsometatarsal joints of the midfoot. Foot Ankle Int. 2003;24(8):584–90. 2. Ouzounian TJ, Shereff MJ. In vitro determination of midfoot motion. Foot Ankle. 1989;10:140–6. 3. Berlet GC, Anderson RB.  Tendon arthroplasty for basal fourth and fifth metatarsal arthritis. Foot Ankle Int. 2002;23(5):440–6. 4. Komenda GA, Myerson MS, Biddinger KR.  Results of arthrodesis of the tarsometatarsal joints after traumatic injury. J Bone Joint Surg. 1996;78A:1665–76. 5. Mann RA, Prieskorn D, Sobel M.  Mid-tarsal and tarsometatarsal arthrodesis or primary degenerative osteoarthrosis or osteoarthrosis after trauma. J Bone Joint Surg. 1996;78A:1376–85. 6. Sangeorzan BJ, Veith RG, Hansen ST.  Salvage of Lisfranc’s tarsometatarsal joint by arthrodesis. Foot Ankle Int. 1990;10(4):193–200. 7. Berlet GC, Hyer CF, Lee TH, Philbin TM, Hartman JF, Wright ML.  Interpositional arthroplasty of the first MTP joint using a regenerative tissue matrix for the treatment of hallux rigidus. Foot Ankle Int. 2008;29(1):10–21. 8. Shawen SB, Anderson RB, Cohen BE, Hammit MD, Davis WH.  Spherical ceramic interpositional arthroplasty for basal fourth and fifth metatarsal arthritis. Foot Ankle Int. 2007;28(8): 896–901.

Tibialis Anterior Tendon Ruptures

15

Corey M. Fidler and Patrick E. Bull

15.1 Introduction/Case Examples Ruptures of the tibialis anterior tendon are uncommon but will typically present after an acute injury or as either an acute or chronic foot drop. In the setting of an acute injury, the injury mechanism is typically blunt tendon trauma or laceration. Acute ruptures of a healthy tendon are rare [1, 2]. Atraumatic ruptures tend to occur in older individuals with underlying chronic tendinopathy. Those patients with diabetes mellitus, inflammatory arthropathy, or gout, or who are undergoing treatment with corticosteroids, are at higher risk for spontaneous ruptures [3]. A minor traumatic event may involve an eccentric load applied to a plantar-flexed ankle. Physical findings include the presence of a foot drop with a steppage gait, swelling, and discontinuity of the tibialis anterior tendon sheath. Sometimes an anterior ankle palpable mass or pseudotumor may be the chief complaint. In the case of acute injuries, osseous or other soft tissue injuries may accompany the findings of foot drop. An extension deformity of the hallux and/or

C. M. Fidler (*) Carilion Clinic, Department of Orthopaedic Surgery, Roanoke, VA, USA e-mail: [email protected]

digits may also be present as the long extensor tendons attempt to compensate for the lack of ankle dorsiflexion. In the cases of chronic ruptures, there may be contracture of the heel cord which must be addressed if surgical intervention is pursued by adding a gastrocnemius or Achilles tendon lengthening to the procedure selection. Clinical examination alone is usually sufficient for diagnosis of a tibialis anterior tendon rupture; however, in chronic tendon ruptures with no history of trauma, a MRI may be useful in determining the extent of pre-existing tendinopathy and the amount of tendon retraction. Plain film radiographs are rarely valuable unless the intent is to rule out bony pathology or if there is suspicion that a foreign body produced the rupture. In the case of an atraumatic rupture, imaging studies should be reviewed to identify any preexisting tendinopathy that may pursuade the surgeon to consider a tendon transfer. In addition, a MRI may show the presence of a plantaris or peroneus tertius tendon that may be harvested if a graft is needed. The amount of ankle equinus should be fully evaluated, and if the patient is unable to achieve 10° of dorsiflexion, an Achilles tendon or gastrocnemius lengthening should be performed.

P. E. Bull Orthopedic Foot & Ankle Center, Worthington, OH, USA © Springer Nature Switzerland AG 2019 C. F. Hyer et al. (eds.), Essential Foot and Ankle Surgical Techniques, https://doi.org/10.1007/978-3-030-14778-5_15

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15.1.1 Surgical Technique The patient is placed in the supine position. General anesthesia is administered with the addition of a popliteal and saphenous nerve block. A thigh tourniquet is used and the leg is exsanguinated for hemostasis. Once the patient is under general anesthesia, and complete muscle relaxation is achieved, the presence of equinus is tested utilizing the Silfverskiold test. A gastrocnemius recession or Achilles tendon lengthening is performed if necessary (Chap. 31). Surgical management is indicated in younger, more active patients, while lower-­ demand patients can be treated either surgically or conservatively with a custom ankle-foot orthosis (AFO). Surgical options include direct apposition of the tendon or repair with either autograft tendon transfer or allograft reconstruction. Our preferred technique for tendons that are unable to be directly apposed is to transfer the adjacent extensor hallucis longus tendon. A standard anterior medial incision is made directly over the course of the tibialis anterior tendon that begins proximally at the level of the superior extensor tendon retinaculum and ends distally at the level of the medial cuneiform. Meticulous soft tissue handling is utilized to help prevent wound complications along the anterior ankle. The superior and inferior extensor retinaculum is incised and tagged with suture for repair during closure to help prevent adhesions after repair. Occasioanlly, the superior extensor retinaculum can be preserved by isolating the proximal stump and shuttling it inferiorly and deep to the retinacular layer. This ensures an intact superior retinaculum and decreases the liklihood of post-operative scarring and tendon “bowstringing”. The tibialis anterior sheath is incised and the proximal and distal stumps are isolated. Occasionally there is sufficient existing tendon for direct apposition; however, if there is concern that the repair will be incompetent, or if no tendon excursion is appreciated, then proceed with the extensor hallucis longus (EHL) tendon transfer. Direct tendon repair, when possible, is performed with a 2-0 nonabsorb-

C. M. Fidler and P. E. Bull

able braided high stength suture using a Krakow with gift-box suture pattern. The proximal aspect of the EHL tendon is in a separate tendon sheath adjacent to the tibialis anterior tendon. A separate 4-cm incision is made over the distal EHL tendon. Identify both the EHL and extensor hallucis brevis (EHBr) tendons. The EHL tendon is harvested just proximal to the first metatarsal phalangeal joint while ensuring adequate length remains for EHBr tenodesis. The EHL can be pulled proximally into the tibialis anterior exposure field. Place a whip stitch with 0 nonabsorbable suture through the distal end of the harvested EHL tendon. Abundant EHL length is the norm, but if graft length is compromised, many fixation options exist to complete the transfer. A short EHL tendon can be secured to the medial cuneiform with a suture anchor or an interference screw. Ideally, the EHL is secured through a drill hole placed from dorsal to plantar through the medial cuneiform. The tendon is passed from dorsal to plantar and looped through the bone, brought dorsally along the medial cuneiform, and sutured back on itself. We prefer to pass the tendon through the medial cuneiform, place an interference screw, and then sew the looped tendon back upon itself in a “belt and suspenders” technique. It is important to secure the transfer with the foot in approximately 10° of ankle dorsiflexion. Use a high-strength nonabsorbable braided suture 2–0 or larger for the tenodesis. The proximal tibialis anterior tendon stump is then tensioned and sutured side-to-side to the adjacent EHL tendon with 0 nonabsorbable suture. A side-to-side anastomosis is also performed between the distal EHL stump and the EHBr tendon with the hallux maintained in 10–15° of dorsiflexion. Tenodesis with the hallux in neutral dorsiflexion can lead to disappointing hallux extensor lag postoperatively. To avoid wound healing complications and tendon “bowstringing,” take care to close the tibialis anterior tendon sheath and extensor retinacula with absorbable suture. The ankle is then splinted in 10° of dorsiflexion (Figs. 15.1, 15.2, 15.3, and 15.4).

15  Tibialis Anterior Tendon Ruptures

Fig. 15.1  A separate 2–4-cm incision is made over the distal extensor hallucis longus (EHL) tendon. The tendon is harvested proximal to the first metatarsal phalangeal joint with care taken to leave a distal stump large enough to attach to the EHB tendon. A side-to-side anastomosis is performed to the extensor hallucis brevis tendon

Fig. 15.2  A whip stitch is placed with 0 nonabsorbable suture through the end of the harvested extensor hallucis longus tendon. Gentle traction is applied to ensure there is adequate length of the tendon for its attachment to the medial cuneiform

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Fig. 15.3  Proximally, a side-to-side anastomosis is performed to the EHL and tibialis anterior tendons using 0 nonabsorbable suture

Fig. 15.4  The completed repair

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15.2 Post-Op Care Please refer to Chap. 1 for a detailed description of the postoperative protocols for all procedures.

Pearls and Pitfalls

In cases of chronic tibialis anterior rupture, before proceeding with surgical reconstruction, it is critical to identify and treat all conditions that may have attributed to the tendon degeneration, and those that may affect healing negatively. Nicotine use must be eliminated. Diabetics must demonstrate effective blood sugar control by maintaining their hemoglobin A1c 50% tendon involvement. With the Achilles tendon retracted in some fashion, dissection down through subcutaneous tissue and Bovie crossing vessels in retrocalcaneal fat. • Dissection is carried through the deep fascial compartment, and the FHL muscle belly is present. DF and PF the hallux for confirmation. • Harvest through same incision as distally as possible with the ankle maximally plantar flexed to increase excursion and length. • Use army-navy to protect tibial nerve sharply transect with scalpel. • Whip stitch the tendon with 0 Vicryl or a nonabsorbable suture. • A guidewire for the interference screw is placed central on the superior dorsal aspect of the calcaneus, avoiding the STJ. • Drive the wire out of the bottom of the foot (avoid WB surface and plantar fascia insertion). • Drill the hole to the size measured of the FHL tendon with the goal size being either the same size of the tendon or one size larger. Do not drill the plantar cortex. • Place the cut end of the sutures attached to the FHL through the slot in the guidewire. Hemostat the sharp end of the wire distally. • Pull on the wire distally out of the bottom of the foot; pull on the sutures to dial in precise tendon of FHL. • Insert interference screw centrally with foot in 10–15° of PF. • Run 0 vicryl suture to repair the longitudinal split.

Chronic Rupture • Direct end to end repair are possible for gaps 2.5 g/dL and a total lymphocyte count of >1500/μL in order to proceed with an amputation [2]. Blood glucose control  – An ideal diabetic patient will have an A1c reading of 7.0% or less. Since the A1c percentage is being read over time, it may be hard to see that direct change during a hospitalization; therefore, we recommend blood glucose reading to be as normal as possible (less than 150 mg/dL) to optimize healing. This is best achieved by having the admitting medical service remove all maintenance diabetes medications and having the patient managed with sliding-­scale insulin or continuous intravenous insulin [3–5]. Vascular assessment  – To determine the appropriate level of amputation, it is most appropriate to perform a vascular assessment. Now in most cases, a simple pulse exam or ankle-­ brachial index (ABI) is enough to determine

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s­ uccess. An ABI of >0.5 should be sufficient for healing [2]. However, if the exam warrants arteriography to evaluate and/or perform intervention on the femoral or iliac vessels, this should be planned ahead of the BKA if possible. Cardiopulmonary reserves – In the case where the BKA is more elective, such as in the case of chronic deformity or pain, one must consider the patient’s cardiopulmonary reserves. A BKA will require energy expenditure to ambulate compared to a preserved limb [6]. Nicotine use – As with all foot and ankle surgeries, nicotine use is prohibited. By technical measure, nicotine metabolites are detectible in the blood for 6 weeks post last exposure, and secondhand smoke is indeed nicotine exposure. It is recommended that no patient undergoes BKA with nicotine consumption due to the deleterious effects on wound healing. Social support – The patient and family should be given an opportunity to meet with social services and prosthetic services prior to the BKA when possible. This eases anxiety and allows for equipment planning.

39.1.3 Positioning, Tourniquet Placement, and Sterile Preparation The patient’s position is supine for this procedure. It is recommended to place a hip bump to point the foot vertically. A thigh tourniquet is standardly applied in the normal position at the top of the thigh, as close to the crease of the hip/groin as possible. We suggest 300 mm Hg, never to exceed 2 hours of continuous tourniquet time. The sterile preparation can be done from the malleoli to the thigh tourniquet drape. Should the foot have active infection and/or an open wound, it is recommended to keep this part of the limb isolated from the sterile field. This isolation is done with an impervious stocking drape and Coban wrap (see Tip below). Tip  The impervious stocking and Coban drape of the foot (Fig. 39.1).

Fig. 39.1  Dressing out the foot with draining wounds with an impervious stockinette and Coban wrap

39.1.4 Back Table and Mayo Stand Setup In general, there will be the need for a separate set of tools and instruments to perform a BKA. An amputation kit has larger instruments than typically seen in a foot and ankle kit. Such instruments that may be useful are large skin rakes, large Homan retractors, a large bone rasp, a large key elevator, and an amputation knife. Since speed and efficiency are important factors in performing BKA, attention to the proper setup of the Mayo stand should be done before incision. This will allow for the necessary instruments to be readily available in the early part of the procedure. In general, the Mayo stand will house #10 scalpel blades, periosteal key elevators, retractors, and a saw. Additional equipment for the standard BKA include silk suture ties and/or vascular clips for hemostasis.

39.1.5 Procedure 39.1.5.1 Incision There are multiple descriptions and calculations in the literature designed to help the surgeon plan the incision for a BKA. The standard BKA is a

39 Amputations

posterior flap brought anterior with a myoplasty of the gastrocnemius to the anterior-proximal tibia. Therefore, the incision is an anterior transverse incision (4 fingerbreadths ~ 8  cm) below the tibial tubercle, then linear down the medial and lateral lower leg, and, finally, transverse posteriorly connecting the medial and lateral linear incisions (Figs. 39.2 and 39.3). The width of the anterior incision is determined by the width of the lower part of the lower leg. In other words, the maximum width proximally is determined by the minimum width distally. The length of the posterior flap is adjusted

Fig. 39.2  Incision planning of the length from the tibial tubercle

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after the limb is amputated; therefore, the surgeon should keep as much of the posterior flap as possible at this stage. The incision is full thickness with a #10 blade. The incision is carried down cleanly to the deep tissues, including the muscle and periosteum. The incision should be started anteriorly, then down each side of the lower leg, and finally across the posterior leg. Posteriorly, the incision does not usually complete the amputation. This will be done with an amputation knife after the bone cuts are made.

39.1.5.2 Amputation A large rake retractor is placed proximally over the tibia, and subperiosteal elevation on the anterior tibial periosteum is done to a level 2  cm proximal to the skin incision. A power saw is then used to transversely cut through 90% of the tibia. By leaving 10% of the tibia intact, this keeps the leg stable while the remaining dissection is performed (see Tip below). The rake is then moved laterally to help expose the fibula. The saw is then used to transact the fibula slightly more proximal than the tibial cut. The fibular cut is also angled from medial-distal to proximal-­ lateral creating a bevel that is more suited to fitting in the prosthetic socket. Tip  Incomplete tibial resection for stability (Fig. 39.4). Now the remaining 10% of the tibia is either transected or fractured by bending the osteotomy

Fig. 39.3  Incision planning showing the fully drawn-out incision

Fig. 39.4  Incomplete tibial resection maintains stability until the limb is ready to be removed

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Fig. 39.5  The posterior “peel”

site over the surgeon’s arm. The tibia and fibula are then pulled anteriorly stripping the lower leg from the gastrocnemius muscle. The gastrocnemius muscle is what is left behind to create the posterior flap. This “peel” technique allows for a clean dissection that is actually less traumatic (see Tip below). The remaining crural fascia and Achilles tendon is transected using the amputation knife. The leg is then removed and sent to pathology. Tip  The posterior flap peel technique (Fig. 39.5). The saw can now be used to make an anterior bevel on the tibia if desired. A rasp may be used to smooth the edges of the bone where necessary. It is important that the fibula remains shorter than the tibia for proper prosthetic fit and comfort.

39.1.5.3 H  emostasis and Nerve Identification Hemostasis is an important step and should not be ignored. The three major vessels of the lower leg (anterior tibial, posterior tibial, and peroneal arteries) should be identified and clamped with hemostats. Silk sutures or vessel clips should be used for the permanent hemostasis. It is preferred to let the tourniquet down after isolating the three

Fig. 39.6 The medium Hemovac drain and Opsite dressing

major vessels to ensure no other sources of significant bleeding are identified. The tibial nerve, common peroneal nerve, and sural nerve should all be put on stretch and truncated short of the bone cuts. This should be done sharply with a scalpel. This technique diminishes the likelihood of painful neuroma formation. The last step in this portion of the surgery is to place a drain if necessary. It is particularly useful to have a drain in place for 24–48 hours postoperatively if coagulation parameters are not normal. The preferred drain is a medium Hemovac drain that lies against the tibial bone cut end and exits proximal-laterally. It is secured with an Opsite dressing to protect it from premature removal while allowing for ease of removal without having to disrupt the dressings or splint (see Tip below). Tip  Hemovac drain security (Figs. 39.6 and 39.7).

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control postoperative swelling, it is recommended to place a long leg split. Rigid postoperative immobilization is also the best form of pain control prevention of phantom pains.

39.1.6 Immediate Postoperative Care

Fig. 39.7  The drain secured

39.1.5.4 M  yoplasty and Flap Length Adjustment The posterior flap is secured by the myoplasty technique. The crural fascia is sutured to the anterior tibial periosteum after adjusting the length of the posterior flap. The posterior flap adjustment is done by bringing the flap forward with Kocher clamps and then using a marking pen to measure and adjust the length. Sharp dissection is done with a #10 scalpel. A watertight closure is done with size 0 or #1 Vicryl suture. After this fascial closure, the skin will be approximated in layers. 39.1.5.5 Closure The skin is closed in two layers. The subcuticular layer is approximated with size 2.0 Vicryl suture, and the final layer is closed with the surgeon’s choice of staples or sutures. The final position of the incision should be anterior to the distal end of the stump. And should the surgeon encounter “dog ear” deformity at the corners, it is best advised not to adjust or make additional incisions. Adjusting for these deformities is often associated with additional wound breakdown. 39.1.5.6 Dressing and Immobilization An antimicrobial contact dressing is applied to the incision. Gauze and/or ABD dressings are then applied and secured using rolled cotton batting. To prevent contracture at the knee and to

The rigid splint is kept in place for approximately 3  weeks. The drain however can be removed at 24–48  hours postoperatively. In general, the sutures are removed at roughly 3  weeks. Most patients will be immediately fitted for stump shrinkers at this point.

39.1.7 Prosthesis Fitting and Long-­ Term Care The fitting of the stump shrinkers begins the process of shaping the stump to accept a prosthetic leg. Usually the prosthetists take over the timing of the fitting of the prosthetic leg at this point. There are certain factors in determining the fitting of the prosthetic leg (swelling, pin, wound healing, etc.). Some patients will be fitted with a temporary leg that allows them to stand and transfer early in the postoperative period. Provided that the patient is doing well, most will be walking at around 2  months postoperatively. Younger patients, whose amputations were performed for reasons such as trauma and/or severe deformity, may actually walk within days to weeks of the surgery.

39.2 Ertl Modification of the BKA 39.2.1 Indications As with below-the-knee amputations, the indications for the Ertl modification are similar. Most patients have complications leading to the need for amputation, including diabetes or peripheral vascular disease with non-healing wounds. Of particular concern with the Ertl modification is the viability of the residual distal fibula. Patients

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described, a well-padded tourniquet is placed about the upper thigh and set to 250 mm Hg, not to exceed 2 hours of continuous inflation.

39.2.4 Surgical Technique

Fig. 39.8  Anterior-posterior modification

X-ray

of

the

Ertl

presenting with pathology that jeopardizes the health of the fibula are excluded, including patients presenting with proximal extension of infection or vascular insufficiency (Fig. 39.8).

39.2.2 Preoperative Assessment In order to ensure the success of the Ertl procedure, full-length plain radiographs are necessary of the tibia and fibula. This allows for thorough surgical planning should any anatomic variations or retained hardware exist. An MRI of the extremity may be useful in the setting of prior infection or concerns of osteomyelitis. An angiogram is obtained for concerns regarding distal perfusion that may impair healing of the osteomyoplastic reconstruction. The general medical workup and optimization of the patient is identical to that performed for a BKA and is presented earlier in this chapter.

39.2.3 Patient Positioning Patient positioning on the surgical table is identical to that of a BKA, with a large positioning bump fashioned and placed under the ipsilateral hip to internally rotate the lower leg and to better present the fibula. A black foam ramp pad is used to slightly elevate the lower leg to minimize venous congestion and bleeding. As previously

The standard approach to a below-the-knee amputation is described earlier in this chapter. In the Ertl approach, care must be exercised to avoid stripping the soft tissues off of the fibula distally. Preservation and appropriate handling of the periosteal tissue is of the utmost importance to avoid avascular changes of the distal bone. Maintaining the proximal periosteal attachment to the fibula preserves the peroneal arterial supply to the bony bridge. Periosteal flaps are developed distal to the level of the planned osteotomies to use for incorporation around the fibular bone bridge. These flaps are created in anterior-to-­posterior direction, creating a medial- and lateral-­based flap off the tibia and the fibula. The periosteal layers are elevated off the tibia and fibula while maintaining cortical bone attachments to the periosteal layer to facilitate bony union. Tip  It is recommended to use a 45° chisel to elevate the periosteum to avoid cutting the tissue. The use of an osteotome for elevation risks cutting the periosteal tissue. Unlike in a traditional BKA, the tibial and fibular osteotomies are created at the same level. The surgeon’s preference is used in guiding the orientation of the osteotomies. Tip  The author’s preference is to maintain the lateral cortex of the fibula and medial cortex of the tibia once transverse osteotomies are made. These cortical struts then allow the rotated fibular graft to be sandwiched between the cortical bones to create a “press-fit” construct. The use of internal fixation to secure the fibular graft is at the discretion of the surgeon. The original description of the Ertl procedure requires no internal fixation; however, options for fixation vary from small fragment screws to

39 Amputations

suture-button fixation or nonabsorbable suture via bone tunnels. Once the bone bridge is adequately secured, focus turns to the closure of the periosteal flap. The tibial and fibular flaps are sutured together in a tubelike fashion around the fibular bridge. The lateral fibular periosteum is sutured to the medial tibial periosteum creating a 180° vascular soft tissue sling inferior to the graft. The corresponding superior tissues are secured in a similar fashion enveloping the fibular graft. Reconstruction with closure of the medullary canals allows the restoration of the intramedullary pressure and reduces the incidence of a crown sequestrum. The myoplasty step requires suture fixation of the posterior flap to the osteoperiosteal bridge to anchor the myodesis.

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39.2.7 Complications Although every surgical procedure has the potential for complications, there are several unique concerns that arise with the Ertl technique. The creation of an osseous bridge as a primary feature of the procedure introduces the risk of non-union. Careful attention to dissection with preservation of the periosteal flap, meticulous closure, and stable fixation will help to reduce this risk. Certain modifications of the technique call for the use of internal fixation devices to secure the osseous bridge, which may introduce the potential for hardware irritation. With a sufficient soft tissue envelope and care to avoid prominence of the hardware, this risk is reduced. Heterotopic ossification may be seen in cases in which there is an incomplete closure of the medullary canal of the tibia or fibula. More common complications can include delayed wound healing or sinus tract formation, skin adherence to the bone, joint contractures, insensate skin, and residual pain.

Tip  The author’s preference is to create a myodesis between the posterior compartment and the anterior/lateral compartment musculature through suture fixation. This step improves venous return from the extremity through restoration of the pumping actions of the agonist-­ antagonist muscular relationship. 39.3

39.2.5 Closure The closure of the Ertl below-the-knee amputation is similar to the closure of the standard below-the-knee amputation. Attention must be paid to obtaining adequate soft tissue coverage from the myodesis over the fibular strut graft due to the end bearing nature of the procedure.

39.2.6 Postoperative Care In addition to the standard postoperative care described earlier in this chapter, the surgeon must continue to monitor the healing and stability of the osteoplastic reconstruction. Serial radiographs are obtained in the office every 4 weeks until sufficient callus formation is noted to ensure a stable bone bridge. Weight-bearing on the limb is generally allowed between 6 and 8 weeks but made on a case-by-case basis.

Midfoot Amputations

39.3.1 Indications Anatomically the foot can be segregated into three areas when considering a midfoot amputation. These areas dictate the level of amputation and the anatomic structures that can be spared. The Chopart joints describe the transverse tarsal joints between the midfoot and hindfoot, specifically addressing the talonavicular and calcaneocuboid joints. Distally, the transition between the midfoot and forefoot occurs between the metatarsals and the tarsal bones, which is referred to as the Lisfranc joint complex. As with other types of amputations, the indications for midfoot amputations are similar. Most patients present with a variety of risk factors that predispose them to a compromised soft tissue envelope around the forefoot. Systemic diseases including diabetes, neuropathy, and/or peripheral vascular disease are most commonly associated with wound development and a subsequent failure to heal.

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39.3.2 Preoperative Assessment

39.4 Transmetatarsal Amputation

Preoperative workup of the patient requires a complete understanding of barriers that may interfere with success of the operation. Plain radiographs are obtained of the foot and ankle to identify potential anatomic variations or retained hardware. An MRI of the extremity may be useful in the setting of prior infection or for concerns of osteomyelitis. An angiogram may be obtained when distal perfusion of the limb is suspected to be impaired. The general medical workup and optimization of the patient is identical to that performed for a BKA and is presented earlier in this chapter.

A full-thickness transverse incision is developed in a curvilinear fashion across the central portion of the metatarsals. Cutaneous branches of the peroneal nerve are identified and transected sharply under light traction with the nerve end buried in the adjacent muscle. The dorsalis pedis artery is identified with an attempt to preserve the continuity of the artery as it passes plantarly to complete the arterial anastomosis with the posterior tibial artery. The artery should be ligated proximal to the skin margin to protect the residual vessel. The extensor tendons are placed under tension by plantarflexing the forefoot prior to transecting sharply and allowing them to retract proximally. The metatarsals are then visualized, and the level of osteotomy is determined. With the use of an oscillating saw, the metatarsals are individually resected attempting to maintain approximately half to one-third of the proximal metatarsal.

39.3.3 Patient Positioning Patient positioning on the surgical table is performed with a positioning bump placed under the ipsilateral hip to internally rotate the foot until it is directly pointed upward. A black foam ramp pad is used to slightly elevate the lower leg to minimize venous congestion and bleeding. In order to achieve vascular control during the procedure, a tourniquet is typically utilized. The preference of a well-padded thigh tourniquet or an Esmarch tourniquet around the ankle is left to the discretion of the surgeon but should not be allowed to exceed 2 hours.

39.3.4 Surgical Technique The approach to a midfoot amputation is based upon the level of the amputation determined during the preoperative planning. Although the level of bony resection will differ, a similar surgical approach is used for the incision and soft tissue dissection. Initially the limb is exsanguinated to limit blood loss. Tip  Amputations performed in the setting of a localized infection are best done with gravity exsanguination to avoid using the Esmarch over the infected area and risking manual expression of infection into adjacent areas.

Tip  Metatarsal resections are best done with a beveled cut at 30–45° angling from dorsal-distal to plantar-proximal, maintaining the normal cascade of the metatarsal lengths. This direction of osteotomy reduces plantar pressure on the residual foot and reduces the potential risk of future ulceration. It is suggested that the first and fifth metatarsals are evaluated for residual sharp edges following osteotomy that may create additional pressure on the skin. The plantar portion of the incision is then completed at a 45° distal-plantar direction from the dorsal incision to allow the longer plantar flap of the incision to be rotated dorsally to avoid placing pressure on the incision during weight-­ bearing and with placement of a shoe. The plantar neurovascular structures are ligated and cut sharply as they are identified. Sharply divide flexor tendons while under tension to allow tendons to retract proximally. Tip  In distal midfoot amputations, skin quality can oftentimes be marginal. It is important to remember that the quality of the soft tissues outweighs the importance of the quantity of the soft

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tissue available for closure. Therefore, if poor-­ quality tissue is available for the closure of a transmetatarsal amputation, the surgeon should consider amputation at a more proximal level. If a long plantar flap is unable to be developed due to soft tissue quality, a fishmouth incision may also be used.

sals, connecting the midpoint of the first metatarsal base medially to the base of the fifth metatarsal laterally. These landmarks are adjusted slightly more proximal with the Chopart amputation with a dorsal curvilinear incision placed over the Lisfranc joints but starting medially just distal to the talonavicular joint and terminating laterally at the calcaneocuboid joint. Although the location of the incision may Prior to closure, the tourniquet is released to ensure adequate hemostasis. If excessive oozing vary, the surgical approach is identical for both from the bony resection is encountered, a small procedures. Once a dorsal full-thickness flap is percutaneous drain deep to the fascia may be developed, the cutaneous branches of the peroplaced. The short-term success of the procedure neal nerve are identified and transected sharply is based upon meticulous closure of the soft under light traction. The dorsalis pedis artery is tissue envelope with edge-to-edge skin re-­ identified and ligated proximal to the skin mar­ approximation. The closure is performed in a lay- gin. The extensor tendons are placed under tenered fashion with absorbable deep sutures and sion by plantarflexing the forefoot prior to nonabsorbable superficial sutures, to include the transecting sharply and allowing them to retract proximally. fascia, subcuticular layer, and skin. Amputations through the Lisfranc joints Tip  Contracture of the Achilles tendon is often expose the individual tarsometatarsal joints. found to coexist in patients with plantar forefoot These joints are then disarticulated sharply until ulcerations. When performing any midfoot ampu- the forefoot is detached from the midfoot. The tations, the surgeon should evaluate for the pres- area of disarticulation in Chopart amputations ence of a contracture and consider performing a occurs between the talonavicular and calcaneosimultaneous Achilles lengthening procedure. cuboid joints in a similar fashion, detaching the The lengthening procedure chosen is at the dis- midfoot from the hindfoot. Any prominent areas cretion of the surgeon but should take into con- of bone are removed to avoid excessive pressure sideration the severity of the contracture, on the soft tissues. Sharp edges can be smoothed postoperative wound care needs, subsequent and beveled with a rasp or saw. weight-bearing status, and overall function of the patient. Tip  Dependent upon the anatomy of the patient’s foot, the prominence of the talar head medially or the anterior process of the calcaneus laterally may require partial resection to avoid pressure 39.5 Lisfranc and Chopart on the incision during closure. Amputations Surgeons specializing in the foot and ankle should be familiar with several options for midfoot amputations in order to accommodate patients presenting with varying traumatic injuries or soft tissue complications of the forefoot. Patients should be assessed on an individual basis to determine their potential benefits and risks associated with each of these options. The anatomic landmarks for Lisfranc amputations are based on a dorsal curvilinear incision placed along the proximal third of the metatar-

The plantar portion of the incision is then completed at a 45° distal-plantar direction from the area of disarticulation to develop a longer plantar flap. This longer flap typically extends to the level of the metatarsals and can then be rotated dorsally to take advantage of the thicker plantar skin to protect the residual foot with weight-bearing. Tip  Should the quality of the skin plantarly be of concern, a fishmouth-shaped incision may be

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required with adjustments made to the level of skin incision dorsally. As with any type of amputation, the quality of the soft tissues strongly outweighs the importance of the quantity of tissue available for closure. The plantar neurovascular structures are ligated and cut sharply as they are identified. Sharply divide flexor tendons while under tension to allow tendons to retract proximally. With division of the plantar soft tissues, the skin incision is completed plantarly to complete the amputation. Tip  Amputations through the Chopart joints result in the release of the tibialis anterior and posterior tibial tendons which can lead to a progressive plantar flexion deformity of the residual limb. Each of these tendons is tagged when released to perform a dynamic transfer of the tendons. To avoid the foot being pulled into inversion and plantar flexion, the posterior tibial tendon can be rerouted through the interosseous membrane and transferred to the dorsal neck of the talus. The tibialis anterior tendon can also be used as a dynamic transfer to the dorsal-lateral neck of the talus to aid in dorsiflexion. Prior to closure the tourniquet is released to ensure meticulous hemostasis. The use of a percutaneous drain placed deep to the fascia is left to the discretion of the surgeon. In an effort to appropriately tension the tissues around the amputation site and maximize postoperative function, the plantar flap is myodesed to the tarsal bones (Lisfranc amputations) or the talus/calcaneus (Chopart amputations) through bone tunnels. Tip  The contracture of the Achilles tendon is often found to coexist in patients with plantar forefoot ulcerations. When performing any midfoot amputations, the surgeon should evaluate for the presence of a contracture and consider performing a simultaneous Achilles lengthening procedure. The lengthening procedure chosen is at the discretion of the surgeon but should take into

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consideration the severity of the contracture, postoperative wound care needs, subsequent weight-bearing status, and overall function of the patient. A meticulous layered closure of the soft tissue envelope around the residual foot with edge-to-­ edge skin re-approximation helps to avoid early postoperative complications. A combination of absorbable deep sutures and nonabsorbable superficial sutures allows repair of the fascia, subcuticular layer, and skin.

39.5.1 Postoperative Care Immediately postoperatively the patient is placed into a protective surgical dressing. The incision is protected until sutures are safe to remove based upon swelling and healing, which occurs between 10  days and 3  weeks. Immobilization of the residual limb in a postoperative rigid dressing or splint is necessary in cases of Chopart amputations to protect the tendon transfers. Care is taken with a Chopart amputation to avoid dorsiflexion of the foot until the tendon transfers are healed. Weight-bearing is generally restricted for the first few weeks to limit swelling and to protect the incision. Weight-bearing is typically initiated during the 2–4-week mark with the use of a controlled ankle motion (CAM) boot walker once the surgeon determines that the incision and soft tissues are mature enough to tolerate tension on the skin.

39.5.2 Complications Patients undergoing surgical amputations have similar risk factors, including wound dehiscence, infection, and the need for further surgery or higher level of amputation. In addition, the risks of heterotopic ossification, sinus tract formation, skin adherence to the bone, joint contractures, insensate skin, and residual pain continue to be present but are less likely with amputations of the midfoot.

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References 1. Via M.  The malnutrition of obesity: micronutrient deficiencies that promote diabetes. ISRN Endocronol. 2012;2012:103472. 2. Pinzur MS, Stuck RM, Sage R, Hunt N, Rabinovich Z. Syme ankle disarticulation in patients with diabetes. J Bone Joint Surg Am. 2003;85:1667–72. 3. Garber AJ, Moghissi ES, Bransome ED Jr, et  al. American College of Endocrinology position state-

457 ment on inpatient diabetes and metabolic control. Endocr Pract. 2004;10(1):77–82. 4. Clement S, Braithwite SS, Magee MF, et  al. Management of diabetes and hyperglycemia in hospitals. Diabetes Care. 2004;27(2):553–91. 5. American Diabetes Association. Standards of medical care in diabetes: 2008. Diabetes Care. 2008;31(suppl 1):S12–54. 6. Pinzur MS, Gold J, Schwartz D, Gross N.  Energy demands for walking in dysvascular amputees as related to the level of amputation. Orthopedics. 1992;15:1033–7.

Grafting and Biologics

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Ryan T. Scott, Christopher F. Hyer, Gregory C. Berlet, Terrence M. Philbin, Patrick E. Bull, and Mark A. Prissel

Key Points

1. Nonunion is a common complication associated with arthrodesis procedures of the ankle and foot frustrating both patients and surgeons. 2. Allograft biologics, such as PDGF, are a viable alternative to autogenous bone grafting with reports indicating equivocal outcomes. 3. Allografts (cancellous chips, DBM) provide structural graft for large deficits.

40.1 Indications for Grafting and Biologics (Fig. 40.1) • • • • • •

Nonunions Malunions Failed total ankle replacement Distraction arthrodesis of the subtalar joint Evans calcaneal osteotomy Cotton osteotomy

R. T. Scott (*) The CORE Institute, Phoenix, AZ, USA C. F. Hyer · G. C. Berlet · T. M. Philbin · P. E. Bull M. A. Prissel Orthopedic Foot & Ankle Center, Worthington, OH, USA

Fig. 40.1  Bulk allograft from a fresh frozen talus to be used to an allograft transplant in the management of an osteochondral lesion of the talus

• Failed midfoot fusions • Failed first metatarsophalangeal joint fusion • Large osteochondral defects of the talus

40.2 Bone Grafting An array of biologics have been widely utilized in ankle and hindfoot arthrodesis for the past several decades. Historically, foot and ankle surgeons have faced significant challenges with regard to achieving a successful arthrodesis. Nonunions lead to poor patient outcomes, chronic disability, and increased healthcare expenditure. Literature reports up to a 40% nonunion rate for ankle arthrodesis, 16% for subtalar joint ­arthrodesis, and

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17–30% for tarsometatarsal joint arthrodesis [1– 4]. More recently, a study by Arner and Santrock [5] reported nonunion rates of approximately 10% in ankle and hindfoot fusions. He noted a significant increase in nonunion rate associated with smoking, avascular necrosis, and surgical error. Delayed union also remains problematic, especially among patients with known risk factors. Fortunately, documented rates of tobacco use are declining in the United States; however, diabetes and other clinical risk factors are still prevalent.

40.2.1 Patients with Increased Risk of Nonunion 1. 2. 3. 4. 5.

Smokers Diabetics Posttraumatic arthritis Revision surgery Renal impairment

Optimizing arthrodesis rates has brought increased emphasis on mechanical stabilization. Arthroscopic techniques along with new locking plate constructs are attempts to facilitate improved arthrodesis outcomes; however, modern techniques demand biologic augmentation in some patients for increasing surgical success. There are four key points in determining the indications for biologics in foot and ankle surgery [6]: 1 . What are the specific indications? 2. Where do biologics belong? 3. Which biologics belong? 4. How is this pertinent to my practice? Once the appropriate patient has been identified for surgery and a biologic is considered, an autograft or allograft is selected. When determining the type of biologic, we should also consider the three bone graft properties: 1. Osteoinductive (a) Direct mesenchymal stem cells to differentiate into osteoblasts. 2. Osteoconductive (a) Provide a scaffold/latticework for new bone formation.

Fig. 40.2  DBM placement for a second and third tarsometatarsal joint fusion

3. Osteogenic (a) Synthesize new bone from within the graft. Bone grafting (allograft  – DBM, cancellous chips) (Fig.  40.2) will contain osteoconductive and osteogenic properties which will help aid in arthrodesis. Autograft remains the “gold standard” in providing all three properties. However, bone graft harvest does carry some risk of increased morbidity to the patient. Recently, the use of platelet-derived growth factor (PDGF), bone morphogenic proteins (BMPs), and mesenchymal stem cells (MSC) has gained favor among surgeons attempting to minimize nonunions and avoid complications associated with autograft. Negatives associated with autograft: 1 . Chronic pain at the harvest site 2. Seroma/hematoma 3. Wound complications 4. Increased surgical time The use of bone marrow aspirate (BMA) added to bone allograft has been an alternative to autologous bone graft harvest [7]. The concept here is to supplement the osteoconductive properties of the demineralized bone matrix with osteoprogenitor cells from the BMA.  BMA is typically easy to harvest from multiple sites and carries less morbidity than autologous bone graft harvest. Daigre et al. [8] noted there was no significant chronic pain from the BMA harvest in the distal tibia and iliac crest; however, they did find some residual pain from calcaneal BMA which may be confounded by the ipsilateral sur-

40  Grafting and Biologics

gical site. Hyer et al. [9] noted the highest concentration of osteoprogenitor cells stemmed from the iliac crest when compared to the tibia and calcaneus. These aspirate-matrix composites may be combined with allograft preparations, resulting in a product that promotes osteoconduction, osteoinduction, and osteogenesis with limited morbidity. Products such as BMP, MSCs, and PDGF bone graft are indicated for use as an alternative to autograft in arthrodesis of the ankle (tibiotalar joint) and/or hindfoot (including subtalar, talonavicular, and calcaneocuboid joints, alone or in combination). These biological grafts are typically used in those patients with high risk of nonunion and cases of revision surgery. There are numerous studies demonstrating efficacy of each of the respective biologics. Bulk allografts can be used in revision surgery of the forefoot and hindfoot. We typically think of the use of an allograft Cotton or Evans wedge in the reconstruction of a symptomatic flexible flatfoot deformity; however, bulk allograft may also be utilized during a distraction arthrodesis of the subtalar joint or a joint salvage procedure after a failed first ray surgery (first MTP implant). Larger bulk allografts (femoral heads and fresh frozen talus) are used in the ankle for chronic osteochondral defects of the talus or even for a failed ankle fusion, total ankle replacement, or hindfoot intramedullary nail. We typically recommend soaking these larger bulk allografts in either BMA or PDGF to increase the likelihood of graft incorporation.

461

Fig. 40.3 Bone marrow aspirate harvest from the calcaneus

Fig. 40.4  Calcaneal autograft harvest from the calcaneus. A lateral window was created with a trephine

40.3 Surgical Technique: BMA (Fig. 40.3) A Jamshidi needle is used to penetrate the donor site (calcaneus, distal tibia, proximal tibia, iliac crest). A 20 cc syringe is then used to extract the bone marrow aspirate. A larger syringe can be considered if additional volume is required for concentrating. If a large volume of BMA is being extracted, make sure to redirect the needle every 5 cc to ensure maximal MSC harvest. The BMA may then be placed into a centrifuge and spun down if desired.

Fig. 40.5 Autograft harvest instruments. Hollow trephine used to create a cortical window and to aid in the harvest of cancellous autograft

462

40.4 Surgical Technique: Autograft Harvest (Figs. 40.4 and 40.5) Autograft harvest all depends on the harvest site and the required graft volume. When 5 cc of autograft is needed, the calcaneus and distal tibia are optimal. When larger volumes are needed, we recommend the proximal tibia and iliac crest. An incision is made over the harvest site on the lateral wall of the calcaneus, medial distal tibia, proximal tibial tubercle (Gerdy’s tubercle), or iliac crest. The incision is deepened carefully to the level of the cortex. A trephine or saw is used to create a “window” in the cortex which is placed on the back table. Once the cortex has been breached, the autograft may be harvested through the use of a trephine, curette, or power harvester. The resultant deficit may be backfilled with DBM or cancellous chips if desired. The cortical wall is then reapproximated and the wound closed. Alternatively, at the discretion of the surgeon, a power harvester can be utilized to penetrate the cortex and capture cancellous bone in a single step. We find a 7 mm power harvester, when used to harvest calcaneal autograft, does not require replacement of the lateral wall.

R. T. Scott et al.

on the market measuring up to 2 cm in length. These grafts may be either cortical or cancellous. We recommend fenestrating the graft and soaking the graft in bone marrow aspirate. If autogenous bone graft is harvested, the graft should initially be placed in the medullary canal to backfill the deficit from the previous

Fig. 40.7  Extraction of a failed first metatarsophalangeal joint arthroplasty

40.5 Surgical Technique: Large Bulk Allografts 40.5.1 Failed First MTP Fusion (Figs. 40.6, 40.7, 40.8, 40.9, 40.10, 40.11, 40.12, 40.13, and 40.14) Once the implant has been removed, a structural graft must be fashioned to fill the deficit. There are several prefashioned grafts available Fig. 40.6  Removal of a fractured silicone first metatarsophalangeal joint arthroplasty

Fig. 40.8  Bony deficit in the first metatarsal shaft following removal of silicone first metatarsophalangeal implant

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463

Fig. 40.10  Bulk allograft placement for revision of the failed first metatarsophalangeal implant

Fig. 40.9  Large deficit at the level of the metatarsophalangeal joint

implant. The allograft is then placed into the deficit and hardware is placed. A fully threaded cancellous screw may be placed obliquely across the fusion site. We recommend either a partially or fully threaded screw to ensure that minimal to no compression is placed across the allograft. Dorsal plating is then utilized with locking and non-locking screws to stabilize the construct.

Fig. 40.11 Insertion of a partially threaded screw obliquely across the allograft. Carefully place this screw to ensure not to overtighten and crush the graft

464

R. T. Scott et al.

40.5.2 Failed Ankle Replacement (Figs. 40.15, 40.16, 40.17, 40.18, 40.19, 40.20, and 40.21) Explant of a failed ankle replacement leaves a large void at the tibiotalar joint. Preparation of the distal tibia and the talar dome is performed by fenestrat-

Fig. 40.12 Spanning stable fixation across the bulk allograft

Fig. 40.15  Large bony deficit following the removal of failed total ankle

Figs. 40.13 and 40.14  AP and lateral radiograph of fixation spanning the bulk allograft in a failed first metatarsophalangeal arthroplasty

40  Grafting and Biologics

Fig. 40.16  Insertion of the calcar bulk allograft for failed total ankle replacement

465

Fig. 40.18  Placement of the guidewire through the central aspect of the femoral calcar for the insertion of intramedullary nail placement

Fig. 40.19  Placement of cancellous chips to fill any voids prior to placement of the intramedullary fixation

Fig. 40.17  Sizing of the femoral calcar for previously failed total ankle

ing the bones. A large bulk allograft, typically a femoral head, is utilized. We recommend using the calcar as the structural graft due to its high-density cortical shell. The femoral head can then be deconstructed removing the cancellous bone and packing any remaining bony voids. We recommend soaking the graft in bone marrow aspirate, platelet-derived

466

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Figs. 40.20 and 40.21  Anterior and lateral radiograph demonstrating calcar femoral bulk allograft with intramedullary nail placement for failed total ankle

growth factor, or bone morphogenic proteins. Intramedullary fixation with a hindfoot nail, with or without external fixation, is suggested.

40.5.3 Distraction Subtalar Joint Fusion (Figs. 40.22, 40.23, and 40.24) Distraction subtalar joint fusion is typically employed in collapsed open reduction internal fixation of the calcaneus, nonunion of previous subtalar joint fusion, malunion, or chronic deformity of the hindfoot. We typically approach the subtalar joint distraction fusion either from a lateral or posterior approach. The lateral approach follows the technique described in the subtalar joint arthrodesis section. Once the joint is prepped, the tricortical allograft is inserted from the lateral side and into the posterior subtalar joint for measurement. The use of a pin distractor will allow ease of graft placement. Once the proper size is determined, the allograft is trimmed to match the articulating surfaces. The tricortical graft can be fenestrated and soaked in BMA or synthetic biologics. The graft is then impacted and fixation is placed. When the posterior approach is preferred, an incision is placed along the lateral aspect of the

Fig. 40.22  Measuring a bulk allograft for a subtalar joint distraction arthrodesis

Achilles tendon. Dissection is taken down to the subtalar joint. Preparation of the joint is performed in a standard fashion. The tricortical wedge (presoaked in BMA/synthetic biologics) is then inserted from posterior to anterior. Cancellous autograft or

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467

References

Fig. 40.23  Soaking a bulk allograft in bone marrow aspirate prior to implantation

Fig. 40.24  Implantation of a bulk allograft soaked in BMA for a distraction subtalar joint arthrodesis

allograft can be placed anterior to the structural tricortical wedge prior to its insertion. Similar to the lateral approach, a pin distractor is helpful for graft placement. Standard fixation is applied.

Pearls

• Adequately prepare arthrodesis site prior to insertion of bone graft. • Use bone marrow aspirate or other growth factors on large bulk allografts. • Measure twice and cut once. • Apply stable fixation across bone graft placement.

1. Frey C, Halikus NM, Vu-Rose T.  Ebramzadeh. A review of ankle arthrodesis: predisposing factors to nonunion. Foot Ankle Int. 1994;15:581–4. 2. Scranton PE. Use of internal compression in arthrodesis of the ankle. J Bone Joint Surg Am. 1985;67-A:550–5. 3. Easley ME, Trnka HJ, Schon LC, Myerson MS.  Isolated subtalar arthrodesis. J Bone Joint Surg Am. 2000;82-A:613–24. 4. Glazebrook M, Beasley W, Daniels T, Evangelista PT, Donahue R, Younger A, Pinzur MS, Baumhauer JF, DiGiovanni CW.  Establishing the relationship between clinical outcome and extent of osseous bridging between computed tomography assessment in isolated hindfoot and ankle fusions. Foot Ankle Int. 2013;34(12):1612–8. 5. Arner JW, Santrock RD. A historical review of common bone graft materials in foot and ankle surgery. Foot Ankle Spec. 2014;7(2):143–51. 6. Lin SS, Montemurro NJ, Krell ES.  Orthobiologics in foot and ankle surgery. J Am Acad Orthop Surg. 2016;24:113–22. 7. Ozaki Y, Nishimura M, Sekiya K, Suehiro F, Kanawa M, Nikawa H, Hamada T, Kato Y.  Comprehensive analysis of chemotactic factors for bone marrow mesenchymal stem cells. Stem Cells Dev. 2007;16(1):119–29. 8. Daigre JL, DeMill SL, Hyer CF. Assessment of bone marrow aspiration site pain in foot and ankle surgery. Foot Ankle Spec. 2016;9(3):215–7. 9. Hyer CF, Berlet GC, Bussewitz BW, Hankins T, Ziegler HL, Philbin TM.  Quantitative assessment of the yield of osteoblastic connective progenitors in bone marrow aspirate from the iliac crest, tibia, calcaneus. J Bone Joint Surg Am. 2013;95(14):1312–6.

Index

A Accessory navicular syndrome, 176, 177 Acetabular reamer, 299, 300 Achilles tendon (AT) injuries, 153, 154, 156, 161, 176, 308 acute rupture, 261 direct open repair, 266 FHL tendon transfer, 267 finding, 262 mini-open, 267 nonoperative management, 265 patient history, 262 patient selection, 263 positioning and equipment, 264 preoperative planning, 264 tendon defects, 267 chronic rupture, 262 findings, 263 nonoperative management, 265 patient history, 263 patient selection, 263 positioning and equipment, 264 preoperative planning, 264 techniques, 268, 269 wound closure, 269 dissection, 266 gelpi retractor/Weitlaner retractor, 272 imaging and diagnostic studies MRI, 264 ultrasound, 264 Xray, 264 insertional Achilles tendinosis, 262 direct insertional repair, 267 FHL tendon transfer, 268 findings, 263 nonoperative management, 265 patient history, 263 patient selection, 264 positioning and equipment, 264 preoperative planning, 264 non insertional Achilles tendinopathy, 262 findings, 263 nonoperative management, 265 patient history, 263 patient selection, 264

positioning and equipment, 264 preoperative planning, 264 techniques, 268 operating room setup hardware, 265, 266 instrumentation, 265 patient positioning, 265 operative technique posterior medial incision, 266 posterior midline incision, 266 posterolateral incision, 266 pathology, 261 post-operative protocol, 269, 272 Sural nerve injury, 272 Adjunctive procedures biologic augments, 409 I and D, 409 negative pressure wound therapy, 409 Adult acquired flatfoot deformity (AAFD), 189, 190, 197, 175, 189, 200 Akin osteotomy, 19, 20, 23, 24 Allis/Kocher forceps, 179 Allograft regenerative tissue matrix (RTM), 85 Anatomic allograft lateral ligament reconstruction procedure technique, 440–443 Ankle adjunctive procedures biologic augments, 409 I and D, 409 negative pressure wound therapy, 409 ankle/STJ TTC nail, 405–408 anterior approach, 400 clinical presentation, 391–393 dissection, 397, 398 dynamic, 404 equipment, 397 external fixation, 404, 405 imaging, 395, 396 internal fixation, 403 intramedullary implants, 403 plate constructs, 404 intraoperative, 410 lateral approach, 398, 399 medial approach, 402

© Springer Nature Switzerland AG 2019 C. F. Hyer et al. (eds.), Essential Foot and Ankle Surgical Techniques, https://doi.org/10.1007/978-3-030-14778-5

469

470 external fixation (cont.) nonoperative treatment, 393, 394 operating room setup, 396, 397 operative treatment, 394 posterior approach, 401, 402 postoperative care, 409 preoperative laboratory testing, 396 quality of life, 391 static, 404 STJ/ TN fusion, 408, 409 surgical fixation, 403 Ankle arthritis, 275, 282, 289, 359 Ankle arthrodesis anterior approach large caliber compression lag screw fixation with anterior anatomic plating, 289 operating room set up/instrumentation/hardware selection, 278 operative technique, 278–281 trans fibular approach, 289 arthroscopic ankle arthrodesis, 276 (See Also Arthroscopic ankle arthrodesis) complications, 282–284 diagnosis, 277 imaging and diagnostic studies, 277, 278 patients history, 276, 277 positioning and fixation of arthrodesis site, 287 post-operative care, 287 Ankle arthroplasty, 275, 284, 359 Ankle arthroscopy complications, 418 instrumentation, 411, 416 operative room setup, 411, 412 postoperative protocol, 418 surgical technique arthroscopic assisted ORIF syndesmosis, 414 arthroscopic micro fracture awls, 416 arthroscopic probe verification, 418 cartilage graft, mixed with bone marrow aspirate, 416 cartilaginous surface, 413 chronic lateral ankle ligament instability, 413 lateral gutter, 413 lateral osteochondral defect, 415 lateral shoulder, 413 loose bodies removed ankle joint, 415 loose bodies within ankle joint, 415 medial shoulder, 412 osteochondral defect, 415, 417 portal entry sites, 417 posterior hindfoot endoscopy portal placement, 418 prone positioning with knee, 417 proper posterior hindfoot endoscopy positioning, 417 resected symptomatic os trigonum, 418 syndesmotic injury, 414 tibiotalar joint, 412 Ankle-brachial index (ABI), 2, 447 Ankle-foot orthosis (AFO), 154 Anteater’s nose, 250 Anterior calcaneal Z osteotomy, 194, 195

Index Anterior cavus deformities, 307, 317 Anterior talofibular ligament (ATFL), 431 Anterior tibial tendon (ATT), 169 Arch restoring, 175 Army Navy retractor, 184 Arthrodesis, 52, 150 Arthroscopic ankle arthrodesis, 290 anterior medial and anterior lateral portals, 289 contraindications, 284 indications, 284 instrumentation/hardware selection, 285–287 operating room set up, 285–287 osteophytes, removal of, 290 synovectomy and exostosis removal, 290 Arthroscopic Broström postoperative protocol, 435 Arthroscopic Broström procedure technique, 432–435 Arthroscopic debridement approach, 382 intraoperative, 388 postioning and equipment, 381 potential complications, 389 preoperative planning, 379 technique, 384 Articular surface involvement, 377 Atraumatic ruptures, 153 Autogenous bone graft, 278 Autograft harvest, 461, 462 Avascular necrosis (AVN), 110 arthroscopic debridement approach, 382 intraoperative, 388 postioning and equipment, 381 potential complications, 389 preoperative planning, 379 technique, 384 articular surface involvement, 377 clinical findings, 377 core decompression approach, 382 intraoperative, 388 postioning and equipment, 381 potential complications, 389 preoperative planning, 379 technique, 384 etiologies, 377 fresh talar bulk allograft approach, 382, 384 intraoperative, 388 positioning and equipmemt, 382 potential complications, 389 preoperative planning, 379 technique, 385 imaging and diagnostic studies, 377 patient history, 377 pre and postoperative radiographs, 377, 378, 380 preoperative planning, 379 surgical treatment, 378, 379 TTC and TC arthrodesis approach, 384 intraoperative, 388 positioning and equipment, 382, 383

Index postoperative care, 389 potential complications, 389 preoperative planning, 379, 381 technique, 385–388 vascularized extensor digitorum brevis flap approach, 382 intraoperative, 388 postioning and equipment, 381 potential complications, 389 preoperative planning, 379 technique, 384 B Below knee amputation (BKA), 1 back table and mayo stand set-up, 448 Ertl modification anterior-posterior X-ray, 452 closure, 453 complications, 453 indications, 451 patient positioning, 452 postoperative care, 453 preoperative assessment, 452 surgical technique, 452–453 immediate post-operative care, 451 indications, 447 preoperative optimization blood glucose control, 447 cardiopulmonary reserves, 448 hemoglobin and hematocrit count, 447 nicotine use, 448 nutritional status, 447 patient’s position, 448 social support, 448 sterile preparation, 448 tourniquet placement, 448 vascular assessment, 447 wound dressing, 448 procedure closure, 451 drain security, 451 dressing and immobilization, 451 flap length adjustment, 451 hemostasis, 450 incision, 449 incomplete tibial resection, 449 medium HemoVac drain and opsite dressing, 450 myoplasty technique, 451 nerve identification, 450 posterior flap peel technique, 450 silk suture ties and/or vascular clips, 448 prosthesis fitting and long-term care, 451 Belt and suspenders approach, 154, 156, 162 Bioabsorbable interference screw, 177 Biologics in foot and ankle surgery, 460 indications, 459 osteoconductive, 460 osteogenic, 460 osteoinductive, 460

471 Bone grafting in ankle and hindfoot arthrodesis, 459 autograft, associated with, 460 autograft harvest, 461, 462 bone marrow aspirate, 460, 461 delayed union, 460 indications, 459 large bulk allografts, 461 distraction subtalar joint fusion, 466, 467 failed ankle replacement, 464–466 failed first MTP fusion, 462–464 nonunion, 460–461 osteoconductive and osteogenic properties, 460 Bone marrow aspirate (BMA), 460, 461 Bone morphogenic proteins (BMPs), 170, 460, 461 Bridle procedure, posterior tibial tendon transfer, 349–352, 354, 355 Brostrom lateral ankle reconstruction, 312 C Calcaneal fibular ligament, 220 Calcaneal osteotomy, 176, 177, 179, 186 Calcaneal Z osteotomy, 189 Calcaneocuboid joint (CCJ), 189, 191–194, 233, 235, 240–242, 245 Calcaneonavicular (CN) coalitions coalition resection, 252, 253 equipment, 252 patient positioning, 252 radiographs, 250 surgical approach, 252 tissue interposition, 253, 254 wound closure, 254 Calcaneus autograft harvest, 31 Calcinosis, 264 Capsulotomy, 117 Cartilage allograft, 95, 96 Cavus, 233, 234 Cavus foot reconstruction, 171, 322 corrected hindfoot and first metatarsal with healed osteotomies, 320, 322 diagnosis and imaging, 310 hindfoot alignment, 323 lateral tuber shift, 321 operative techniques dorsiflexory first metatarsal osteotomy, 314–316 gastrocnemius recession, 312 lateralizing calcaneal osteotomy with/without wedge, 313, 314 Malerba calcaneal Z osteotomy, 314 plantar fascia release, 312, 313 OR setup and instrumentation hardware selection, 311 primary procedure, 311 secondary procedure, 311 supine position, 310 patient presentation, 307–310 postoperative protocol, 321 secondary procedures, 316–319

472 Cerebral palsy (CP), 307 Charcot arthropathy (CA), 150 characteristic of, 157 exostectomy, 157 Hintermann distractor, 158 tendo-Achilles lengthening (TAL), 157 Charcot-Marie-Tooth disease (CMT), 307, 308 Charcot midfoot hardware and instrumentation, 160, 161 operative technique Achilles lengthening, 161 belt and suspenders approach, 162 external fixation, 162 guide pin placement, 164 Hintermann to distract, 162 internal fixation, 163 lateral beam placement, 164 for large rocker-bottom deformities, 161 medial beam placement, 164 medial clip placement, 164 medial column of, 164 osteotomy, 161, 162 postoperative radiographs, 165 preoperative radiographs, 160 TA tendon, 161 wedge resection osteotomy, 161 OR setup, 160 postoperative protocol, 165 post-operative protocol, 165 ST joint, 166 Charcot neuroarthropathy (CN), 121, 122, 168, 170, 291–293, 299 hindfoot and ankle adjunctive procedures, 409 ankle/STJ TTC nail, 405–408 anterior approach, 400 clinical presentation, 391–393 dissection, 397, 398 equipment, 397 external fixation, 404, 405 imaging, 395, 396 internal fixation, 403, 404 intraoperative, 410 lateral approach, 398, 399 nonoperative treatment, 393, 394 operating room setup, 396, 397 operative treatment, 394 posterior approach, 401, 402 postoperative care, 409 preoperative laboratory testing, 396 quality of life, 391 STJ/ TN fusion, 408, 409 surgical fixation, 403 prevalence, 391 Cheilectomy, 70, 93–96 Chronic overuse syndromes, 110 Chronic tendinopathy, 153 Chronic venous insufficiency (CVI), 3 Claw toe correction, 319

Index Claw toe deformities, see Hammertoe and clawtoe deformities Cobb elevator, 202 Cole osteotomy, 311, 316–319 central midfoot incision, 316 fixation, 316, 317 peroneal switch (transfer), 319 primary and revision lateral ankle reconstruction, 318 split tibialis anterior tendon transfer, 317 Steinmann pins, 316 Coleman block test, 308, 309 Collateral ankle ligament repair anatomic repair, 431 deltoid ligament reconstruction, 443 hardware, 432 instrumentation, 432 lateral ankle stabilization, 431 non-anatomic repairs, 431 operating room setup, 432 patient presentation, 431 primary lateral ankle stabilization arthroscopic Broström postoperative protocol, 435 arthroscopic Broström procedure technique, 432–435 open Broström Gould post-operative protocol, 438–439 open Broström-Gould procedure technique, 436–440 revision lateral ankle stabilization, 439–443 syndesmotic ligament injury surgical description, 444, 445 Complex multiplanar foot deformity, 121, 122 Computed tomography (CT), 115, 310 Core decompression approach, 382 intraoperative, 388 postioning and equipment, 381 potential complications, 389 preoperative planning, 379 technique, 384 Coronal plane deformities, 284, 310 Cotton osteotomy, 247 cotton allograft insertion, 145, 147 fluoroscopy aids, 144, 145 heart-shaped distractor insertion, 145, 146 imaging and diagnostic studies, 137–141 intraoperative pearls and pitfalls, 145 patient history and findings, 137 posterior tibial tendon, 137 postoperative care, 148 potential complications, 148 surgical management approach, 143, 144 positioning and equipment, 141, 143 preoperative planning, 141 trial wedges insertion, 145, 146 unicortical osteotomy, 144 Coughlin grading system, 93 Crystalline arthropathy, 93

Index D Deltoid ligament reconstruction, 443 Demineralized bone matrix (DBM), 205 Direct plantar plate repair, 60–62 Disease modifying anti-rheumatics drugs (DMARD), 3 Distal soft tissue procedure (DSTP), 20, 24, 28–30 Distal tarsal tunnel syndrome, 338 Distraction subtalar joint fusion, 466, 467 Dorsal approach neurectomy, 103, 104 Dorsal capsulotomy, 151 Dorsal cheilectomy, 94, 95, 97 Dorsiflexion closing wedge first metatarsal osteotomy, 311 Dorsiflexion osteotomy, 234–236, 247 Dorsiflexory first metatarsal osteotomy, 314–316 Dorsolateral approach, 116–118 Drop foot complications, 353 history, 345 left lower extremity common peroneal nerve function, 344, 350–352 MRI, 345 nerve conduction/electromyographic studies, 345 physical examination, 345 posterior lengthening procedures bridle procedure, posterior tibial tendon transfer, 349–352, 354, 355 endoscopic gastrocsoleus recession, 348 gastrocnemius recession, strayer procedure, 348, 349 open gastrocsoleus recession, 348 percutaneous tendo-Achilles lengthening, 347–348 surgical treatment endoscopic gastrocsoleus recession, 347 open proximal gastrocsoleus recession, 347 patient selection, 346 percutaneous tendo-Achilles lengthening, 347 positioning, 347 preoperative planning, 346 Silfverskiold maneuver, 347 X-ray, 345, 346 Dual incision approach, see Subtalar coalition resection Dwyer calcaneal osteotomy, 311 Dwyer osteotomy, 313 E Ecchymosis, 261 Extensor hallucis longus (EHL) tendon, 41, 42, 279 Endoscopic gastrocsoleus recession (endo-GSR), 348 Equinovarus complications, 353 history, 344 MRI, 345 physical exam findings, 344, 345 posterior lengthening procedures bridle procedure, posterior tibial tendon transfer, 349–352, 354, 355 endoscopic gastrocsoleus recession, 348

473 gastrocnemius recession, strayer procedure, 348, 349 open gastrocsoleus recession, 348 percutaneous tendo-Achilles lengthening, 347–348 surgical treatment endoscopic gastrocsoleus recession, 347 open proximal gastrocsoleus recession, 347 patient selection, 346 percutaneous tendo-Achilles lengthening, 347 positioning, 347 preoperative planning, 346 Silfverskiold maneuver, 347 X-ray, 345, 346 Equinus, 176, 190, 346 Ertl modification anterior-posterior X-ray, 452 closure, 453 complications, 453 indications, 451 patient positioning, 452 postoperative care, 453 preoperative assessment, 452 surgical technique, 452–453 Erythematous foot, 158 Evans osteotomy, 141 Exostectomy, 157 Extensor digitorum brevis (EDB) muscle belly, 218–219, 240, 247, 252 Extensor hallucis brevis (EHBr) tendons, 154 Extensor hallucis longus (EHL) tendon, 86, 144, 154, 156, 314 External fixation (Ex Fix), 404 circular frame, 405 dynamic, 404 static, 404 Extracorporeal shock wave therapy, 265 F Fibular autograft, 380, 399 Fibular osteotomy, 295–297, 398 First metatarsocuneiform joint, 143 First metatarsophalangeal cheilectomy and osteochondral defect treatments, 93, 95 imaging and diagnostic studies, 93, 94 intra-operative pearls and pitfalls, 99 patient history and findings, 93 postoperative radiographs of, 96 post-up care, 99 potential complications, 99 preoperative radiographs of, 95 surgical management approach, 94 positioning and equipment, 94 pre-operative planning, 94 surgical technique cartilage allograft, 95, 96 cheilectomy, 94, 95 subchondral drilling, 95

Index

474 First metatarsophalangeal (MTP) joint, 93, 158 anatomy of plantar aspect, 110 capsuloligamentous structures, injuries to, 109 hallux rigidus, 69 history and physical examination, 69, 70 imaging and diagnostic studies, 70 interpositional arthroplasty case examples, 85, 86 GRAFTJACKET Matrix, 86 Hewson suture passers, 87 intraoperative pearls/pitfalls, 92 joint synovectomy, 86 Keller osteotomy, 87 looped wires, 87 McGlamry elevator, 86 metatarsal head, 87 metatarsal-sesamoid joints, 89 patient history, 85, 86 post-operative care, 90 pre-operative work up, 85, 86 retrograde intramedullary guidewire placement, 87 operative techniques access into joint, 72 AP and lateral pre-op x-rays, 78, 79 denude cartilage, 74 dorsal exostosis removal, 72 dorsal medial incision, 71 final closure and clinical position, 78 fish-scaled, 75 full thickness sub-periosteal dissection, 71 guide wire placement, 72, 73 intra-fragmentary screw placement, 77 locking screw placement, 77 plate positioned with temporary fixation pins, 76 proximal phalanx, 75 OR setup/instrumentation/hardware selection, 70 osseous structures of, 109 revision surgery, 81 AP and lateral post-op x-rays, 81 complications, 82 graft fashioned, 80 intraoperative picture with plate spanning, 81 nonunion/malunion, 77–80 osteotomy, 80 postoperative management, 81, 82 size of graft, 80 sesamoid bones, 109 First metatarsophalangeal osteophytes, 98 First tarsometatarsal (TMT) joints, 145 Fleck sign, 326 Fleischer-Nilsonne method, 59 Flexor digitorum longus (FDL) tendon, 137, 182–185, 202, 203, 206 transfer, 182–185 Flexor hallucis brevis (FHB) tendons, 109, 110, 113, 117 Flexor hallucis longus (FHL) tendon, 109, 114, 117 transfer, 264, 266–269, 272 Flexor stabilization, 52 Focal cartilage defects, 93 Focal osteochondral defect, 94

after dorsal cheilectomy and defect preparation, 97 preoperative T2 MRI coronal and sagittal slices, 98 Foot and ankle reconstruction, 1 Foot deformity, 368 Foot injury, 149 Forefoot-driven cavus, 308 Forefoot supinatus deformity, 141 Forefoot varus deformity, 137 Fourth and fifth tarsometatarsal (TMT) joints athrosis, 149 dorsal capsulotomy, 151 dorsal lateral incision, 151 imaging and diagnostic studies, 150 interpositional arthroplasty, 150 intra-operative pearls and pitfalls, 151 OR set-up, 150–151 post Op care, 151 potential complications, 151 soft tissue interpositional arthoplasty, 150 subchondral bone of MTs, 151 for tendon interposition, 151 Fresh talar bulk allograft approach, 382, 384 intraoperative, 388 positioning and equipment, 382 potential complications, 389 preoperative planning, 379 technique, 385 G Gait analysis, 52, 70, 114, 190, 277, 308 Gastrocnemius equinus, 176 Gastrocnemius recession (GSR), 176, 201 strayer procedure, 348, 349 Gelpi retractor, 219, 298 H Haglund’s deformity, 263, 264 Hallux interphalangeal joint (HIPJ), 311, 319 achilles tendon lengthening, 40 arthrodesis, 39 complications, 49 diagnosis, 40 EHL tendon transfer, 39–40 internal fixation techniques, 42–44 intraoperative pearls and pitfalls, 47 Jones tendon transfer, 39, 44–49 pathology of, 39 patient history, 39 postoperative care, 49 surgical management Adson forceps, 41 extensor hallucis longus (EHL) tendon transection, 41, 42 incision placement planning, 41 patient positioning and equipment, 40 preoperative planning, 40 S-shaped incision, 41 transverse plane deformity, 41

Index Hallux rigidus, 69, 85, 86, 93, 96 Hallux valgus Akin osteotomy, 19, 20, 23, 24 clinical and radiographic evaluation, 15 clinical presentation, 15, 16 complications, 24 distal metatarsal articular angle (DMAA), 15 distal soft tissue procedure, 20, 24 first metatarsophalangeal (MTP) fusion, 16, 19 hallux interphalangeus angle (HIA), 15 hallux valgus angle (HVA), 15 imaging, 20 intermetatarsal angle (IMA), 15 Mau osteotomy, 16, 17, 21 modified Reverdin osteotomy, 16, 17, 21 OR setup, 21 post-op protocol, 24 prevalence, 15 proximal articular set angle (PASA), 15 scarf osteotomies, 16, 18, 19, 21, 22 Hammertoe and claw toe correction, 311 Hammertoe and claw toe deformities associated foot deformities, 52 causes, 51 clinical examination, 52 diagnosis, 51, 53 flexor stabilization, 52 K-wire fixation, 56 non operative treatments, 52 operative room set-up, 53, 54 post-operative protocol, 55, 56 surgical technique, 54, 55 3 stage pathology, 52 treatment arthrodesis, 52 arthroplasty, 52 extensor tenotomy, 53 flexor tendon transfer, 53 flexor tenotomy, 53 plantar plate pathology, 53 skin plasty techniques, 53 Hardware pain, 82 Hemostasis, 448, 450 Heterotopic ossification, 367 Hewson suture passer, 184 Hindfoot adjunctive procedures biologic augments, 409 I and D, 409 negative pressure wound therapy, 409 ankle/STJ TTC nail, 405–408 anterior approach, 400 clinical presentation, 391–393 deformity, 169 dissection, 397, 398 dynamic, 404 equipment, 397 external fixation, 404, 405 fracture, 209 fusion, 311 hindfoot-driven deformity, 308

475 imaging, 395, 396 internal fixation, 403 intramedullary implants, 403 plate constructs, 404 intraoperative, 410 lateral approach, 398, 399 medial approach, 402 nonoperative treatment, 393, 394 operating room setup, 396, 397 operative treatment, 394 osteotomies, 347 posterior approach, 401, 402 postoperative care, 409 preoperative laboratory testing, 396 quality of life, 391 static, 404 STJ/ TN fusion, 408, 409 surgical fixation, 403 valgus deformity, 212 varus deformities, 325 Hintermann distractor, 211, 254, 255 Hintermann retractor, 31, 241–242 Hohmann elevator, 191, 193, 194 Hohmann retractor, 202, 203, 252 Hypertrophied abductor hallucis muscle belly, 338 I Idiopathic distal symmetrical polyneuropathy, 344 Illizarov technique, 162 Inflammatory arthropathy, 150, 153, 275 Insertional Achilles tendinosis (IAT), 262 direct insertional repair, 267 findings, 263 nonoperative management, 265 patient history, 263 patient selection, 264 positioning and equipment, 264 preoperative planning, 264 Interdigital neuroma, 101 Interpositional arthroplasty for first MTPJ case examples, 85, 86 GRAFTJACKET Matrix, 86 Hewson suture passers, 87 intraoperative pearls/pitfalls, 92 joint synovectomy, 86 Keller osteotomy, 87 looped wires, 87 McGlamry elevator, 86 metatarsal head, 87 metatarsal-sesamoid joints, 89 patient history, 85, 86 post-operative care, 90 pre-operative work up, 85, 86 retrograde intramedullary guidewire placement, 87 4th and 5th tarsometatarsal (TMT) joints, 150 Intersesamoid ligament, 109

Index

476 J Jones tendon transfer, 39, 44–49 Jones tenosuspension, 311, 319 K Keith needle, 253, 258 Kidner procedure, 177, 178 L Lachman maneuver/test, 58 Lapidus HAV correction anterior-posterior (AP) radiograph findings, 27 hallux abducto valgus deformity, 27 surgical management calcaneus autograft harvest, 31 distal soft tissue procedure, 28–30 1st tarsometatarsal joint fusion, 31–36 medial longitudinal incision, 28, 29 positioning and equipment, 28 post-operative protocol, 36 silver osteotomy, 31 tarsometatarsal corrective arthrodesis, 28 transverse and sagittal deformities, 27 Large bulk allografts distraction subtalar joint fusion, 466, 467 failed 1st MTP fusion, 463 failed ankle replacement, 464–466 failed first MTP fusion, 462–464 Lateral ankle ligament reconstruction (Brostrom), 311 Lateral ankle stabilization, 431 Lateral column lengthening (LCL) osteotomy anterior calcaneal Z-osteotomy, 194, 195 calcaneal Z Osteotomy final fixation, 193, 194 incisional approach, 192, 193 micro-sagittal saw, 193 pin-based distractor, 193 porous titanium wedge, 193, 194 trial sizers, 193, 194 flatfoot evaluation, 190 instrumentation, 191 MRI, 190 operating room set-up, 190, 191 patient history, 190 post-operative treatment, 195 preoperative lab evaluation, 190 procedure, 189 radiographs, 190 symptoms, 190 traditional technique incisional approach, 191 opening wedge plate, 192 pin based distractor, 191, 192 sagittal saw, 191 tricortical allograft wedge, 191, 192

Lateral column lengthening osteotomy, 141 Lateral metatarsal head osteochondral defect, 96 Lateral sesamoid fracture, 117 Lateralizing calcaneal osteotomy, 167, 312–314 LisFranc fracture, 129, 131, 133, 149 Lisfranc & Chopart amputations anatomic landmarks, 455 closure, 456 complications, 456 dorsalis pedis artery, 455 incision, 455 ligation and cut, 456 postoperative care, 456 post-operative care, 456 L-shaped extensile incision, 117 L-shaped extensile plantar approach, 113–114 M Magnetic resonance imaging (MRI), 86, 94, 96, 102, 115, 121, 170, 264, 310, 326 Malerba calcaneal Z osteotomy, 314 Malerba osteotomy, 315 Malreduced syndesmosis injury, 276 Malunion, 82 Matles exam, 262 Mau osteotomy, 16, 17, 21 Meary’s angle, 200, 212 Medial calcaneal displacement osteotomy (MCDO), 141 Medial cuneiform, 137, 143, 144, 146, 156 Medial displacement calcaneus osteotomy (MDCO), 177–182 Medial double and triple arthrodesis, 317 Medial double arthrodesis Achilles tendon, 201 clinical presentation, 200 Cobb elevator, 202 curved stat, 207 demineralized bone matrix, 205 FHL tendon, 204 imaging, 200 incision planning, 201 interosseous ligament, 203 operating room set-up, 200, 201 peroneal tendon, 204 physical examination, 200 pin-based hintermann distractor, 202, 203 postoperative protocol, 206 postoperative x rays, 198, 199 preoperative x rays, 198, 199 retraction points, 202 spring ligament, 202 STJ, 203–205 3 month post corrected right foot, 200 TNJ, 206 windlass maneuver, 206

Index Medial malleolus osteotomy, 423–426, 429 Medial sesamoid, 118 Medial sesamoid fracture, 116, 117 Mesenchymal stem cells (MSC), 460, 461 Metatarsal-sesamoid disease, 70 Metatarsosesamoid joints, 85 Midfoot amputation patient positioning, 454 preoperative workup, 454 surgical technique, 454 Midfoot cavus, 309 Midfoot fusion (Cole osteotomy), 311, 316–319 central midfoot incision, 316 fixation, 316, 317 peroneal switch (transfer), 319 primary and revision lateral ankle reconstruction, 318 split tibialis anterior tendon transfer, 317 Steinmann pins, 316 Midsubstance Achilles tendinopathy, see Noninsertional Achilles tendinopathy (NIAT) Mild to moderate coronal plane deformities, 277 Minimally invasive/arthroscopic arthrodesis, 275 Modified Kidner procedure, 178 Modified Reverdin osteotomy, 16, 17, 21 Modified Strayer procedure, 176 Modified Watson-Jones or Chrisman-Snook-type procedures, 311 Morton’s extension splint, 96 Morton’s neuroma, 102 Mulder’s sign, 101 Muller-Weiss syndrome, 209 Multiplanar deformity, 57 Myoplasty technique, 451 N Naviculocuneiform (NC) joint, 143, 145, 316 Cobb elevator, 173 complications, 174 diagnosis and imaging, 169, 170 instrumentation and hardware selection, 170 midfoot pain, 167 operative technique, 170–174 OR set-up, 170 patient presentation, 167, 169 post-operative protocol, 172 preoperative planning, 169 Negative pressure wound therapy, 409 Neuroma definition, 101 diagnosis, 102, 103 hardware recommendation, 103 imaging work-up, 102, 103 non-operative treatment, 103 operating room setup and instrumentation, 103 operative technique

477 dorsal approach neurectomy, 103, 104 plantar approach for revision neurectomy, 104, 105, 107 pathogenesis, 101 patient presentation, 101, 102 postoperative protocol, 107 resident resource, 107 Nicotine, 156 Nitinol wire suture passer, 185 Non insertional Achilles tendinopathy (NIAT), 262 findings, 263 nonoperative management, 265 patient history, 263 patient selection, 264 positioning and equipment, 264 preoperative planning, 264 techniques, 268 Nonsteroidal anti-inflammatory drug (NSAID), 95, 96, 102, 121, 325 Nonsteroidal anti-inflammatory medical therapy, 265 Non-weightbearing, 69, 99 O Occupation, 110, 114, 337 Open ankle arthrodesis, 283, 284, 289 Open Broström Gould post-operative protocol, 438–439 Open Broström-Gould procedure technique, 436–440 Open gastrocsoleus recession (GSR), 348 Os peroneum syndrome, 333 Osteochondral lesion of the talus (OLT) arthroscopic treatment with grafting, 428, 429 clinical presentation, 421 distal fibula fracture, 422 hardware, 423 imaging, 421 instrumentation, 422 medial malleolus osteotomy, 425 operative technique medial malleolus osteotomy, 423–426 medial malleolus osteotomy operative technique, 429 tibia plafondplasty, 425–427, 429 OR setup, 422 osteochondral lesion repair, 429 postoperative protocol, 428 surgical indications, 422 treatment, 422 Osteochondral lesion repair, 429 Osteolysis, 367 Osteomyelitis, 275 P Particulated juvenile articular cartilage (PJAC), 96 Pediatric pes planovalgus deformity, 189

478 Percutaneous tendo-Achilles lengthening (TAL), 347–348 Periosteal elevator, 192, 194 Peripheral nerve block, 359 Peroneal switch (transfer), 318 Peroneal tendon disorders, 325 complications, 336 imaging and diagnostic studies MRI, 326 ultrasound, 326 weightbearing radiographs, 326 patient history and findings, 325 postoperative care, 336 surgical management approach, 326, 328 excision os peroneum with tendon repair, 333 fibular groove deepening, 331, 333 peroneal tendon repair, 329, 330 peroneal tenodesis, 331 positioning and equipment, 326 preoperative planning, 326 superior peroneal retinacular repair, 331 tendon transfer vs allograft, reconstruction with, 333–336 tenolysis, 328, 329 Peroneal tendon instability, 331 Peroneal tendon repair, 311 Peroneus longus, 333 brevis transfer, 312 Pes cavus deformities, 307 Pes planovalgus deformity, 141, 189, 209 Pes planovalgus foot type, 137 Pes planus deformity, 175, 176 Physical medicine and rehabilitation (PM&R), 307 Physical therapy, 362 Plantar approaches, 104, 105, 107, 117, 118 Plantar fascia release, 312, 313 Plantar fasciitis clinical findings, 338 imaging and diagnostic studies, 338 patient history, 337 post-operative care, 341 surgical management intri-operative, 341 percutaneous bRf Microtenotomy, 340 positioning and equipment, 339 pre-operative planning, 338 tarsal tunnel release, 339, 340 Plantar plate instability diagnosis, 58, 59 direct plantar plate repair, 60–62 Lachman maneuver/test, 58 operating room setup, 59 operative technique, 59, 60 pathology, 57 patient history, 57 post operative protocol, 65–67 postoperative protocol, 64 preoperative examination, 58 standard Silverskoild test, 57

Index triplane correctional metatarsal osteotomy, 63, 64 Weil metatarsal osteotomy, 63 Platelet derived growth factor (PDGF), 460, 461 Polyethylene removal strategies, 371, 375 Popliteal and adductor canal approach, 289 Posterior cavus deformities, 307–308 Posterior lengthening procedures, 352 bridle procedure, posterior tibial tendon transfer, 349–355 endoscopic gastrocsoleus recession, 348 gastrocnemius recession, strayer procedure, 348, 349 open gastrocsoleus recession, 348 percutaneous tendo-Achilles lengthening, 347–348 Posterior tibial tendon dysfunction (PTTD), 137, 167, 171, 197, 200, 233 accessory navicular syndrome, 176, 177 diagnostic procedure, 177 edema, 175, 176 equinus, 176 flexor digitorum longus transfer, 182–185 imaging, 177 instrumentation, 177 Kidner procedure, 177, 178 MDCO, 178–182 operating room set-up, 177 post operative protocol, 186 stages, 175 Posterior tibial tendon (PTT), 141, 189, 190, 318 Posterior tibial tendon transfer thru interosseous membrane, 311 Post-operative protocols, 9, 12, 13 Post-static dyskinesia, 337 Post-traumatic arthritis, 121, 122, 217, 218 Posttraumatic disease, 307 Preoperative indications and planning conference, 8–11 Preoperative optimization anti-coagulation medications, 2 blood glucose control, 2 chronic edema, 3 DVT risk stratification, 2 nicotine use, 3, 4 nutritional status, 1 rheumatoid arthritis, 3 social support, 4 vascular assessment, 2 Primary and revision lateral ankle reconstruction, 318 Primary interdigital neuroma, 101 Primary lateral ankle stabilization arthroscopic Broström postoperative protocol, 435 arthroscopic Broström procedure technique, 432–435 open Broström Gould post-operative protocol, 438–439 open Broström-Gould procedure technique, 436–440 Primary midfoot osteoarthritis, 121 Proud medial heel, 309 Proximal first metatarsal closing wedge, 316 Proximal first metatarsal osteotomy, 312 Pseudoarthrosis, 82 Pseudo-equinus, 309

Index R Rearfoot deformity, 197, 200 Revision lateral ankle stabilization, 439–443 Revision neurectomy, plantar approach for, 104, 105, 107 Rheumatoid arthritis, 149 Rocker-bottom deformity, 161 S Scarf osteotomies, 16, 18, 19, 21, 22 Second metatarsophalangeal (MTP) joints, 158 Self-retaining retractors, 252, 254, 257 Senn retractors, 252, 254, 257 Septic arthritis, 275 Sharp arthrotomy, 400 Silfverskiold assessment, 312 Silfverskiold maneuver, 347 Silfverskiold test, 101, 154, 176, 201, 210, 263 Silver osteotomy, 31 Single-leg heel raise test, 175, 176 Single-photon emission (SPECT) CT, 278 Sinus tarsi, 219, 220 Small Hohmann retractors, 252 Small Homan retractors, 254, 257 Smith Peterson osteotome, 218, 221 Soffield retractor, 184 Soft tissue interpositional arthoplasty, 150 Solid arthrodesis, 282 Split tibialis anterior tendon, 312 transfer, 311, 317 Strayer lengthening, 211 Strayer procedure, 201 Subchondral drilling, 95, 96 Sub-fibular impingement symptoms, 176 Subtalar coalition resection cannulated guide advantage, 257 arthroereisis sizing, 257 equipment, 257 patient positioning, 257 post-operative care, 258 surgical approach, 257 tissue interposition, 258 wound closure, 258 definition, 254 equipment, 254 K-wire, 255 1x1 cm wedge of bone, 256 patient positioning, 254 PTT and FDL tendon sheaths, 255, 256 soft tissue and periosteum, 255 surgical approach, 254, 255 tissue interposition, 257 wound closure, 257 Subtalar joint (STJ), 197, 201–206 Subtalar joint (STJ) arthrodesis arthrodesis positioning, 220, 223 clinical indications, 218

479 clinical presentation, 217 complications, 226 diagnosis, 217 hardware selection, 218 imaging, 218 incision, 218 instrumentation, 218 joint preparation, 220 curettage technique, 220, 222 fish scaling, 220, 222 OFAC method, 220, 221 subchondral drilling, 220, 222 operation room setup, 218 pathology, 217 post operative protocol, 225 preliminary dissection, 219 screw fixation, 223–225 sinus tarsi, 219, 220 Subtalar joint (STJ) arthroscopy complications, 420 postoperative protocol, 419 setup, 418 surgery, 419, 420 Superior extensor retinaculum (SPR), 325, 326, 330, 331, 333, 335, 336 Superior peroneal retinacular repair, 331 Supple equinus chronic worsening pain, 343, 349 complications, 353 history, 344 physical examination, 344 posterior lengthening procedures bridle procedure, posterior tibial tendon transfer, 349–352, 354, 355 gastrocnemius recession, strayer procedure, 348, 349 open gastrocsoleus recession, 348 percutaneous tendo-Achilles lengthening, 347–348 surgical treatment endoscopic gastrocsoleus recession, 347 open proximal gastrocsoleus recession, 347 patient selection, 346 percutaneous tendo-Achilles lengthening, 347 positioning, 347 preoperative planning, 346 Silfverskiold maneuver, 347 X-ray, 345, 346 Sural nerve injury, 272 Surgical team communication patient passport, 5, 6 screening checklist, 4, 5 surgical request, 4–7 Syndesmotic ligament injury surgical description, 444, 445

480 T Talonavicular joint (TNJ), 201–203, 206 Talonavicular joint (TNJ) arthrodesis computed tomography, 210 diagnosis, 210 hardware selection, 211 instrumentation, 210 operation room set-up, 210 patient history, 209, 213, 214 patient presentation ankle joint fusions, 210 hindfoot complex, 210 medial ankle ligament complex, 210 preoperative counseling, 210 symptoms, 209 weightbearing/ gait analysis, 210 postoperative protocol, 214 radiography, 210 surgical technique, 211, 212 Talonavicular joint (TNJ) fusion, 209–211 Tarsal coalition clinical presentation, 249–250 CT scan, 250, 251 definition, 249 imaging, 250 pes planus with a C-sign, 251 surgical indications, 251 symptoms, 250 treatment, 251 types, 249 Tarsometatarsal (TMT) joint arthrodesis, 140 calcaneal autograft and bone marrow aspirate aid, 135 complications, 135 1st TMT, 124, 125 indications, 122 injection therapy with fluoroscopic guidance, 121 intercuneiform fixation, 135 isolated, 122, 124 low-profile fixation, 135 MRI, 121 operating room set up, 122 post-operative management, 131 preoperative considerations, 121 2nd TMT, 125, 127 3rd TMT, 125, 127 wedge resection, fusion with, 131 Tendo-Achilles lengthening (TAL), 157, 201 Tenodesis, 154 Tenolysis, 328, 329 Tenosynovitis, 175, 176 Thompson squeeze test, 262 Tibialis anterior (TA) tendon, 161, 278, 279 Tibialis anterior (TA) tendon ruptures, 153, 174 belt and suspenders approach, 156 chronic, 156 clinical examination, 153 nicotine, 156 physical findings, 153

Index post operative care, 156 surgical technique, 154–156 wound healing issues, 156 Tibia plafondplasty operative technique, 425–427, 429 Tibial osteotomies, 311 Tibiocalcaneal (TC) arthrodesis approach, 384 intraoperative, 388 positioning and equipment, 382, 383 postoperative care, 389 potential complications, 389 preoperative planning, 379, 381 technique, 385–388 Tibiotalocalcaneal (TTC) arthrodesis, 377 acetabular reamer, 299, 300 ankle and subtalar joints lateral joint exposure, 299 approach, 384 arthritic incongruent valgus ankle, 291, 294 calcaneal axial films, 305 clinical presentation, 291 complications, 305, 306 compression screw fixation, 300, 301 curved osteotome, 297 diagnosis, 293 distal fibula removal, 298 fibular osteotomy, 296, 297 imaging, 293 intramedullary nail fixation, 291, 292 intraoperative, 388 lateral dissection, 296 lateral incision, 295, 297 medial arthrotomy, 298 medial incision, 295, 297 midfoot and hindfoot reconstruction, 291, 294 nail fixation, 302 operating room setup, 293, 295 positioning and equipment, 382, 383 postoperative care, 389 post-operative care, 304 potential complications, 389 preoperative planning, 379, 381 reamer-irrigator-aspirator, 301, 303 sequential reaming, 301, 303 technique, 385–388 toothed lamina spreader, 296, 297 wire placement, 301, 302 Tibiotalocalcaneal (TTC) fusion system, 397 Too many toes sign, 176 Total ankle arthroplasty (TAR) aseptic loosening, 373, 374 complications, 373 diagnostic studies, 368 heterotopic ossification, 367 imaging, 367 implant design, 366 initial fixation, 376 intraoperative, 372 patient selection, 366

Index polyethylene wear, 367 postoperative care, 372, 373 pre-op planning, 375 revision concepts cyst management, 376 foot deformity, 368 loosening, 368 native bone, 368, 375 range of motion, 369 surgeon error, 366 surgical management adjunctive techniques, 371 array of techniques, 371 equipment, 370 joint line restoration, 372, 376 patient communication, 369 polyethylene removal strategies, 371, 375 polymethylmethacrylate removal, 371 positioning, 370 preoperative planning, 369 revision approach, 370 Total ankle replacement (TAR) C-arm fluoroscopy unit, 359 clinical presentation, 358 concomitant procedures, 359–362 contraindications, 358 history, 358 imaging, 358 indications, 357 instrumentation, 359 operative room setup, 358 physical examination, 358 postoperative protocols, 362 technique anterior approach, 359 anterior tibialis tendon sheath, 359, 360 complete subperiosteal dissection, 359, 360 extensor hallucis longus, 359 incision marking, 360 initial rotation and resection, 359, 360 meticulous layered closure, 359, 361 patient positioning, 359 prosthesis, 359, 361 synovectomy, 360 talar cuts, 359, 361 tibial bone resection, 359, 360 Total contact casting (TCC), 394 Trans fibular approach, 289 Transmetatarsal amputation, 454, 455 Transverse plane deformity, 310 Triplane correctional metatarsal osteotomy, 63, 64 Triple arthrodesis, 197 Turf toe, 109 Turf toe and sesamoid injuries, 118 diagnosis, 114 dorsolateral approach, 117 imaging, 114, 115 medial and lateral sesamoid bones, 109 medial 1st MTP joint approach, 116, 117

481 medial sesamoid excision and torn medial collateral ligament repair, 111–113 Abductor Hallucis into defect, 113 Abductor Hallucis tendon, 113 bi-cortical screw fixation, 112 capsular exposure, 112 capsular repair, 113 chronic ununited medial sesamoid fracture, 111 excised medial sesamoid with cartilage loss, 112 FHB tendon, 113 fragmentation of proximal fragment, 112 lateral shift neutralizing valgus forces, 112 L-shaped capsulotomy, 112 medial approach, 112 medial collateral ligament injury and intra-­ articular damage, 111 medial eminence removal, 112 weight-bearing AP x-ray, 113 weight-bearing assessment, 111 weight-bearing examination, 113 non-surgical treatment, 118 operative technique, 116 OR setup, 116 plantar plate, 109 plantar plate repair, 113–114 post operative protocol, 118 presentation, 114 Two-incision triple arthrodesis cavus, 233, 234 clinical presentation, 235, 236 complications, 247, 248 diagnosis, 237 dorsal talonavicular dislocation and diminutive talus, 235, 236 high arch and plantarflexed hallux, 234, 236 imaging, 237 multiple synostoses and hindfoot malalignment, 235, 236 operating room setup, 239 posterior tibial tendon dysfunction, 233 post-operative care, 247 surgical technique calcaneocuboid joint fixation, 245 dorsal talonavicular joint incision, 242, 243 FHL tendon exposure, 241, 242 flushing, fenestrating, and fish scaling, 243 Hintermann retractor, 242 incision, 239, 240 intra-operative fluoroscopic images, 244–246 joint fenestration and fish scaling, 242 lamina spreader, 241 lateral dissection, 240, 241 orthobiologic supplementation, 244 posterior facet of STJ, 241 reduction and realignment of subtalar joint, 245 reduction and realignment of talonavicular joint, 244 small joint distractor, 243 talar head preparation, 243 triple arthrodesis and dorsiflexion osteotomy, 235, 236

Index

482 U Unctional limitus, 70 Unicortical osteotomy, 144 V Valgus deformity, 238, 239, 241, 244 Varus deformity, 233, 237, 244 Vascularized extensor digitorum brevis flap approach, 382 intraoperative, 388 postioning and equipment, 381

potential complications, 389 preoperative planning, 379 technique, 384 W Wedge resection osteotomy, 161 Weightbearing, 69, 70, 81, 93, 98, 169, 209 Weil metatarsal osteotomy, 63 Weitlander retractor, 60, 219 Windlass mechanism, 206