1. Session III Lesser rays Mr. V. Dhukaram

2. Warwick Orthopaedics is a centre of excellence for research, teaching and development of the treatment of musculoskeletal disease. I am delighted to welcome you all for the Warwick Cadaveric Foot and Ankle Surgery course. This course is designed to be practical with no formal lectures. We have put together the educational and product information for you to familiarise prior to the course which would be a valuable adjunct to the course. Vivek DHUKARAM

3. Patho-Anatomy of lesser toe deformities Intrinsics(Lumbricals & Interossei) maintain MTPJ in neutral where long extensors and flexors act at IPJ Muscle imbalance or intrinsic weakness lead to deformities

4. Lesser Toe Deformities DeformityMTPJPIPJDIPJ ModelClinical picture Hammer toe Neutral/ hyper- extended Plantar flexed Neutral/ hyper- extended Claw toeHyper- extended Plantar flexed Mallet toeNeutral Plantar flexed Curly toeNeutral / plantar flexed Plantar flexed

5. Mallet toe DIPJ Fusion technique - Transverse or longitudinal incision Extensor tendon and release collateral ligaments Resect head of MP and curette base of DP articular surface Retrograde or Antegrade fixation from tip of toe to base of middle/proximal phalanx with 1.4/1.6mm k wire 1.4mm Fixed Def. – DIPJ fusion Flexible – FDL tenotomy Coughlin Operative repair of the mallet toe. FAI 16(3):109-116. 1995

6. Summary of Surgical treatment of Hammer toes & Claw toes MTPJPIPJ Recommendation Flexible FDL transfer(Girdlestone- Taylor)/ Flexor tenotomy(FDL) FlexibleFixedMTPJ release + PIPJ fusion Sublux/ Dislocate FixedWeils + PIPJ fusion, Stainsby (Prox. hemiphalangectomy) UnstableFDL transfer Claw toes will require additional DIPJ fusion/ tenotomy / FDL transfer depending on its flexibility

7. Girdlestone -Taylor (FDL transfer) FDL to takeover the function of Intrinsics to maintain MTPJ in neutral

8. Flexor tenotomy Vs FDL transfer Flexor tenotomy JBJS 84 Ross et al age 10 years old, 62 children 95% satisfaction -188 toes Hamer et al. RCT JBJS 93b 4 year follow up No difference between flexor tenotomy and flexor transfer

9. Metatarso-phalangeal joint release (MTPJ) Sequential staged release of MTPJ depending on the severity and correction of deformity through dorsal longitudinal incision EDL & EDB ‘z’ lengthening Dorsal capsulotomy Collateral ligament release Reduction of Plantar plate Lesser MT osteotomy Dhukaram et.al Hammer Toe Correction with extended metatarso phalangeal joint release JBJS[Br] 84-B Sep 2002 (986–90)

10. PIPJ Fusion Technique (similar to DIPJ Fusion) Elliptical transverse or longitudinal incision Extensor tendon and release collateral ligaments Resect head of PP and curette art. surface base of MP Use double ended 1.4/1.6mm k wire and predrill the PP Retrograde fixation from base of MP distally and drive k wire through predrilled PP Common complications of PIPJ fusion include malunion, floating toe, residual pain, non-union Upto 1/3 rd could have fibrous union but only 1 to 2% symptomatic Lehman reported 15% dissatisfaction in 100 feet Lehman et. Al Treatment of Symptomatic hammertoe with PIPJ arthrodesis. Foot Ank Int. 16(9):535-541. 1995

11. Alternate Methods PIPJ Excisional arthroplasty Similar to PIPJ fusion but EDL tendon interposed between PP & MP and sutured to distal slip in tension No k wire fixation Maintains mild PIPJ flexion rather straight Alternate Fixation for PIPJ fusion Stay Fuse implant Smart toe implant

12. Weils Osteotomy Indications: Metatarsalgia due to long lesser ray or short first ray, Unstable lesser MTPJ, Subluxed/ dislocated MTPJ including Rheumatoid foot Aim to shorten the lesser ray and restoration of metatarsal parabola Proximal sliding of MT head alone doesn’t result in elevation but metatarsalgia shifts proximally. It requires adding additional wedge

13. Weils A Wedge is added to elevate MT head to reduce risk of metatarsalgia and floating toe Fixation method – Twistoff screws Barouk LS. Forefoot Reconstruction

14. Technique Dorsal longitudinal incision EDL & EDB ‘z’ lengthening Dorsal capsulotomy Collateral ligament release Reduction of Plantar plate Osteotomy parallel to sole of feet with wedge Fixation with twistoff screw Removal of dorsal lip Medio-lateral translation of MT head to correct corresponding lesser toe deformities Complications: Stiffness due to arthrofibrosis MTPJ Floating toe – Oblique cut and proximal translation of MT head could move center of rotation of MTPJ plantar to intrinsics so intrinsics act as dorsiflexor of toe Metatarsalgia due to excessive plantar displacement of MT head or failed to restore parabola Hofstaetter et al The weil osteotomy: A seven year follow-up. JBJS 87:1507-1511. 2005

15. BRT osteotomy Isolated metatarsalgia due to depression of MT head but normal length (parabola) Aim to elevate the metatarsal head Osteotomy 60degrees to sole of feet, preserve plantar hinge Fixation with 2.3mm Barouk or twistoff screw Preserve plantar hinge Forefoot reconstruction LS Barouk

16. Stainsby Procedure Indication: Salvage procedure for dislocated MTPJ. The displaced plantar plate exerts plunger effect on MT head Technique: Dorsal approach Subtotal phalangectomy Reduce plantar plate and fatpad under metatarsal head and stabilise with K wire Flexor and extensor tendons are sutured together to provide additional stability Briggs PJ, Stainsby GD. Metatarsal head preservation in forefoot arthroplasty. Foot Ankle Surg 2001; 7:93-101 Hossain S et al. Stainsby procedure for non-rheumatoid claw toes. Foot Ankle Surg 2003; 9:113-8 Proximal subtotal phalangectomy Reduction of plantar plate

17. Lesser Metatarsal head Resection Hoffman Fowler procedure – Dorsal & Plantar incisions

18. Lesser Metatarsal head Resection Clayton – Dorsal incision Kates Lipscomb- Webspace incisions

19. Rheumatoid Foot Surgery Coughlin JBJS Am 2000 Mann JBJS Am 1984 Ist MTPJ arthrodesis and lesser metatarsal head excision -96% subjective - Excellent to good results Many studies reporting pan MTPJ resection – recognised to be associated with high recurrence rate

20. Bunionette Type 1 – large, wide 5 th metatarsal head Type 2 – lateral 5 th metatarsal shaft bowing Type 3 – increased 4th/5th MT angle Any combination of 1 - 3 proposed by Koti & Mafulli Coughlin Combination of type II & III

21. Bunionette Lateral incision Scarf osteotomy for bunionette is gaining popularity Fixation method – Twistoff screw/ Mini- fragment screw Defor mity Surgical Options Type IShaving 5 th MT head or Distal MT Osteotomy – Chevron/ Weil/ Oblique Type IIDistal MT osteotomy – Oblique or Midshaft oblique MT osteotomy Type III Midshaft Oblique Osteotomy or Proximal Osteotomy Coughlin Guha et.al 'Reverse' scarf osteotomy for bunionette correction: Initial results of a new surgical technique. Foot Ankle Surg. 2012 Mar;18(1):50-4.

22. Mortons Neuroma Not a true neuroma but a degenerative lesion Common in 3 rd webspace followed by 2 nd & 4 th Approach – Dorsal, Plantar (scar sensitivity) Divide inter-metatarsal ligament and bury the proximal stump to lower the risk of recurrence Akermark :Similar outcome with dorsal and plantar incisions. Higher scar problems with plantar approach and missed neuroma with Dorsal approach Akermark et. Al Plantar versus dorsal incision in the treatment of primary intermetatarsal Morton's neuroma. FAI 2008 Feb;29(2):136-41 Nery et.al Plantar approach for excision of a Morton neuroma: a long-term follow-up study. JBJS A 2012 Apr 4;94(7):654-8. Dorsal Webspace Appoach