5/8/2014 Conflicts of interest Instability of the lesser • Arthrex- consultant MTP joints • Arthrex- royalties (Crossover 2 nd toe deformity) • Elsevier-book royalties -my 25 year journey- Michael J Coughlin, M.D. Progressive MTP joint Early Diagnosis subluxation Coughlin,M. The Crossover toe Foot Ankle Int 1987 1
5/8/2014 Surgery -1987-2011- Capsular reefing Soft tissue balancing • Extensor tenotomy, lengthening • Medial/dorsal capsulotomy Coughlin, M.J.: When to suspect crossover second toe deformity. J. Musculoskeletal Medicine 1987. Flexor Tendon Transfer MEDIOCRE RESULTS Partial proximal phalangectomy Metatarsal condylectomy 1 2 Akin-ette MTP joint arthrodesis Amputation Metatarsal osteotomy 3 4 2
5/8/2014 All of these treatments Grading and Staging • Never really treated the (Barcelona-2011) problem! -8 fellows- • Indirect repairs - saved 12 specimens over 7 years- • Never saw the pathology • (the plantar plate tear) PUBLISHED: Metatarsophalangeal joint pathology in crossover second toe deformity: a cadaveric study. Foot Ankle Int. 33:133-140, 2012 Grade 1 Grade 2 transverse tear < 50% Transverse distal > 50% GRADE 2 Removed met. head 3
5/8/2014 Grade 3 Grade 4 Transverse and longitudinal, no repairable capsule extensive FDL PHALANX Phalanx FATPAD GRADE 4 GRADE 3 We then devised a Stage 1 clinical staging system • To help us • Mild MTP joint malalignment with our • Plantar MTP joint pain clinical • Swelling MTP joint (plantar) • Mild + drawer (subluxable, examination <50%) 4
5/8/2014 Physical Examination Physical Examination Positive Drawer Positive Drawer • Pathopneumonic Stage 3 Stage 2 • Severe malaligment • Moderate malalignment • Plantar MTP joint • Reduced swelling?? pain • No toe purchase • Little swelling • ++ positive drawer • Very positive drawer – Can dislocate 5
5/8/2014 Began defining the extent of Stage 4 the plantar plate tear • Very severe deformity • Dislocation • Fixed hammertoe • Little or no swelling • ? Painless drawer Weil osteotomy We then developed a technique to expose and repair the plantar plate 6
5/8/2014 Incision Deepening the incision Direct dorsal interspace incision Multiple joints? Neuroma present? Versatile exposure Unsure of the diagnosis? Extensor brevis is available for transfer later Proximal capsular release McGlamry Base of Met head proximal phalanx Plantar blood supply Proximal synovial attachment Plantar Plate Yes- we routinely release the proximal capsule Does it destroy the circulation to the metatarsal head? NO Courtesy of LS Weil, Jr.. DPM It does give 2-3 mm. more expansion of the joint 7
5/8/2014 Proximal translation of Distraction and visualization the Weil Medial and lateral collateral Releasing the plantar plate ligament release So it is completely released!! 8
5/8/2014 Exposing the tear Example Free it up from the base of the proximal phalanx, and the flexor tendon Plantar plate takedown Passing the sutures • Try the two different types of Micro-scorpion 9
5/8/2014 Scorpion suture #1 Scorpion suture #2 Suture number 8. Exposing the base of the Suture pattern proximal phalanx Towel clip on the phalanx, and twist downward 10
5/8/2014 Exposing the base of the proximal Fixing the Weil phalanx Tying the sutures Plantar flex the PP 20 degrees Cartilage against cartilage Neutral deviation 11
5/8/2014 Prospective study • Coughlin, M.J.: Lesser toe deformities. Orthopaedics 10(1):63-75, 1987. • Two year study • Coughlin, M.J.: Crossover second toe deformity. Foot & Ankle 8:29- 39, 1987. • Coughlin, M.J.: When to suspect crossover second toe deformity. J. • 100 patients Musculoskeletal Medicine 39-48, 1987. • Coughlin, M.J. Schenck, Jr., R.C., Shurnas, P.J.., Bloome,D.M. Concurrent interdigital neuroma and MTP joint instability: long-term • Improved stability results of treatment. Foot and Ankle Int. 23:1018-1025, 2002. • Coughlin, M.J.: Subluxation and dislocation of the second • Marked resolution of pain metatarsophalangeal joint. Ortho. Clinics of North America 20(4):535-551, 1989. • Coughlin, M.J.: Second metatarsophalangeal joint instability in the • Nery C, Coughlin M, Baumfeld D. Second MTP joint instability: athlete. Foot & Ankle 14(6):309-319, 1993. grading of the deformity and description of surgical repair of capsular insufficiency. FAI – April 2012 • Coughlin M. Lesser toe abnormalities. AAOS Instructional Course Lectures. 52:421-444, 2003 • Coughlin M, Schutt S, Hirose,C, Kennedy M, Grebing B, Smith B, Cooper T, Golano P Viladot R, Alvarez F. Metatarsophalangeal joint • Coughlin M, Grimes, J.S. Geometric Analysis of the Weil Osteotomy. pathology in crossover second toe deformity: a cadaveric study. Foot Foot Ankle Int. 27:985-992, 2006 Ankle Int. 33:133-140, 2012 • Kaz A, Coughlin M. Crossover second toe: demographics, etiology • Nery C, Coughlin M, Baumfield D, Mann, T. Instabilidade das and radiographic assessment. Foot Ankle Int. 1221-1237, 2007 articuladoes metatarsofalagicas e lesoes da plcas plantares: estudo • Nery C, Coughlin M. Arthroscopy and MRI evaluation of second MTP clinico e morfologicl. Journal of the Brazilian Foot and Ankle Society joint capsular insufficiety. Submitted to FAI-May 2012 5:63-72, 2011 • • Second MTP Joint Instability: Grading of the Deformity and Description of Surgical Repair of Capsular Insufficiency., Coughlin M,Baumfield D,Nery . Physician and Sports Medicine, 39:132-141, 2011 12
Recommend
More recommend
