Digital Surgery Complications - ASPS · •Revision of failed foot surgery: a critical analysis...

Digital Surgery Complications

Zeeshan S. Husain, DPM, FACFAS, FASPSGreat Lakes Foot and Ankle Institute

September 21, 2018

Annual Surgical Conference 2018

Disclosures

• None

Presentation Outline

• Differentials– Neuroma– Plantar plate injury– Metatarsalgia– Hammertoe

• Influencing factors– Anatomy

• Hammertoe• Rigidity• Plane(s) of deformity

• Complications

Presentation Outline

• Differentials– Neuroma– Plantar plate injury– Metatarsalgia– Hammertoe

• Influencing factors– Anatomy

• Hammertoe• Rigidity• Plane(s) of deformity

• Complications

• Treatment options– Arthrodesis– Tendon transfers

• Flexor tenotomy• Girdlestone-Taylor

– Variations

• EDB transfer• Hibbs

• What have I learned?– Arthroplasty needs to be

retired

Plantar Plate

• Subjective– “Walking on pebble”– Wart under foot– Pain

• Under MPJ• MPJ effusion

• Biomechanical– Hammertoe– Hallux abductovalgus– Elongated 2nd metatarsal1

– Equinus

• Iatrogenic– Steroid2

1. Klein, et al, Foot Ankle Spec 6:2, 2013.

2. Reis, et al., J Bone Joint Surg 71B:5, 1989.

Differential Diagnoses

• Misdiagnosis– Capsulitis / Synovitis– Freiberg’s disease– Arthritides– Stress fracture– Neuroma1

• Single 97/279

– 3rd interspace 74.2%

• Multiple 182/279

– 2nd interspace 98.9%– 3rd interspace 100.0%

1. Valero, et al., J Foot Ankle Surg 54:3, 2015.

2nd MPJ plantar exposure

2nd IMS neuroma

The Plantar Plate

• Plantar plate function– Stabilize MPJ with lumbricales

and FDL– Resists DF tensile forces– Offers gliding surface for flexor

tendons– Weakest at base of phalanx1

– Assists Windlass mechanism

• Lachman test– DF toe at 25°– Translate dorsally / plantarly

1. Jolly, in Master Techniques in Podiatric Surgery: The Foot and Ankle, ed. Chang, Lippincott,

Williams and Wilkins, Philadelphia, 2005.

Staging MPJ Instability

• Stage 1– Subtle edema with pain to plantar MPJ– Most (70-90%) alleviate in several days

• Stage 2– Moderate edema– Radiographic deviation of digit– Loss of toe purchase– Poor response to conservative treatment

• Stage 3– Moderate edema– Frank subluxation/dislocation– Often seen with HAV deformity– Rarely responds to conservative treatment

Yu and Judge, in Reconstructive Surgery of Foot and Leg, editors Camasta, et al., Podiatry

Institute Publishing, pp109-13, 1995.

Staging MPJ Instability

• Grade 0- No instability– No joint pain, thickening, or swelling

– Prodromal phase but no deformity

• Grade 1- Mild instability– Synovitis and mild deviation

– Positive drawer sign without significant deformity

• Grade 2- Moderate instability– Dorsomedial deviation/subluxation

– Positive drawer sign with deformity

• Grade 3- Dislocated MPJ– Positive drawer sign with cross-over deformity

• Grade 4- Rigid dislocated MPJ

Haddad, et al., Foot Ankle Int 20:12, 1999.

Imaging

• Radiographs

• Ultrasound• Dynamic

• Arthrogram

• MRI

Imaging

• Radiographs


• Arthrogram

• MRIMTH

Base of

phalanx

Imaging

• Radiographs


• Arthrogram

• MRI

Normal plantar plate

MTH

Base of

phalanx

Imaging

• Radiographs


• Arthrogram

• MRI

Imaging

• Radiographs


• Arthrogram

• MRI

Yao, et al., Am J Roentgenol 163:3, 1994.

Imaging

• Radiographs


• Arthrogram

• MRI

Hammertoe Complications

• Reproducibility– Predictable results

• Arthrodesis

– Retire the arthroplasty

• Typical complications– Incision contracture– Prolonged swelling– Floating toe– Poor purchase– Deviated toe if

performing arthroplasty– Issues with K-wires

Hammertoe Complications

• Proposed algorithm– Rigid?

• PIPJ arthrodesis

– Flexible?• Restore MPJ and PIPJ

congruency with tendon transfer(s)

– Goals• Restore FDL function• Joint congruency• Correct transverse plane

deformity

• Reproducibility– Predictable results

• Arthrodesis

– Retire the arthroplasty

• Typical complications– Incision contracture– Prolonged swelling– Floating toe– Poor purchase– Deviated toe if

performing arthroplasty– Issues with K-wires

Literature

• Revision of failed foot surgery: a critical analysis– n = 244

– Most common reason for revision• Transfer metatarsalgia• Recurrent bunion• Lesser digit deformity

– Satisfaction rates after revision• Revisions- 176/244• 24% with reservations• 6% dissatisfied

Kilmartin, J Foot Ankle Surg 41:5, 2002.

Literature

• Complications of digital and lesser metatarsal surgery– Risk factors and co-morbidities

– Wound healing and infectious complications

– Smoking

– Implant failure and management

– Acute digital correction of longstanding toe deformities

– AVN of lesser metatarsals following surgery

– Floating and flail toe deformity

Bibbo, et al., Clin Podiatr Med Surg 27:4, 2010.

Distal Metatarsal Osteotomy

• Indications– Metatarsalgia– Metatarsal parabola– Plantar plate techniques

• Floating toe rates– Migues, et al.

• Incidence– Osteotomy alone 28.5%– With digital correction 50.0%

– Highlander, et al.• Incidence

– Floating toe 36.0%

Migues, et al., Foot Ankle Int 25:9, 2004.

Highlander, et al., Foot Ankle Spec 4:3, 2011.

Malposition

• Considerations– Level of deformity– Influence of adjacent

digits– Osseous versus soft

tissue

Optimizing Results

• Recognizing pathology– Anatomy

– Plantar plate injury?

– Rigidity

– Plane(s) of deformity

• Predictable outcomes– Arthrodesis

– Tendon transfers• FDL

• EDB

Trethowan, Lancet 205:5312, 1925.

Taylor, J Bone Joint Surg 33B, 1951.

Forrester-Brown, J Bone Joint Surg 20A:1,

1938.

• Direct plantar approach

Case Scenario- Plantar Plate

• Dorsal surgical approach

– Metatarsal osteotomy

– Plantar plate exposure

– Suture plantar plate

– Phalanx suture tunnels

– Tension repair

– Metatarsal fixation



• What did I do?– Repaired attenuated ligament– Will it hold?

• Alternative– FDL tendon transfer

Reinforce correction with steri-strips

Pre-op

Post-op

Case Scenario- FDL Transfer

• Surgical approach

– PIPJ preparation

– FDL tendon

– Bone tunnel

– Tension tendon

– Bone anchor

Case Scenario- EDB Transfer

1


– Metatarsal bone tunnel• Pass suture under

deep intermetatarsal ligament

– Proximal phalanx bone tunnel

– Adjust tension

* Downey, et al., in McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery,

ed. Southerland, et al., Lippincott, Williams and Wilkins, Philadephia, 2013.

*






– Adjust tension

2



*






– Adjust tension

3



*






– Adjust tension



*

Post-operatively

• Cicatrix contracture

• Splintage– K-wire– Bandaging– Taping– Splinting

• Weightbearing status– Surgical shoe

Conclusions

• Accurate diagnosis– Determine deforming

factors

• Balance expectations

• Be definitive on surgical procedures– Arthrodesis– Tendon transfers

Thank You

Zeeshan S. Husain, DPM, FACFAS, [email protected]

Annual Surgical Conference 2018

Digital Surgery Complications - ASPS · •Revision of failed foot surgery: a critical analysis...

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