'FORETOETSIJRGERY

FOREFOOTSURGER.Y
FOREFOOTSURGERY
FOREFOOTSURGERY
FOREFOOTSURGERY
FOREFOOTSIJRGERY
FOREFOOTSURGERY
FOREFOOTSI.-IRGERY
FORE,FOOTS1JRGERY
F'OREF'OOT
SL]RGERY
F'OREFOOTSIJRGERY
F'OREFOOTSTJRGERY
FOREFOOTSTJRGtrRY
F'OREFOOTST]RGtrRY
-',"
FO i].-EFOCT St- R{i i-:F.l.
Fi-iR: FCliiT S,L.F..aj I i'.':
.:'
F{iKE F TJOT ST*'Rlji- ij
FLiRt FOiiT SL Rr*,i-ir.":
FOF.SFOOT SUR.iJFR.',
j? -:
F*iiF F OOT :ij t_,.,_
i),-
SL xi-; Fir.,
;-OFI-EF{*}eT
 ACCESSOR)' RONES OF THE FOOT A\]D A\.KL[

Accesson'Bttncs
. Det'elopmental Aromalles
. Ma]'be nruluple ut tle foot
. Unilateral rn > -50ozo
of cases

Nlost Common
. Os Trigonunt
. Os Tibiale Exernum
. Os InlermeEtarseum

Os Trigonum
. Near posterolateraltutrrcle of uJus
. "lnlerns Fracrure''
"Tngonal hcrcess"
. Wlren fused - called
. ]r4ore ofien bilateral
. Frequeno' = 2.7 - 7.79'o

Os Tihiale f,rternurn / Acccsson'Navicular

. lncorporated['T. PostenorTendon
. T)?icalll'prramidal rn shape
' Fibrous or fibrocanilapnou(
connecllon
. Frequencr'= -i - l20zi,
Tlpe l
. Reall]'a sesamoidbone rn T
posterior tendon
. Round Sesamoid:
. Sesamoids
Accounl for 30ozi,
Tl'pe U
. Accesso4' ossif;catroncenteri-n Fars peronee
the navicuiar nrelalaselia Os
. In ermgl al ar setlln
Separatedfiom naricr.rlarbodr'
Os iriercuneilorme
br'fibrocanilage
. Triangulat Processus
uncinslus Os versalianum pedis

os lntermelatant'um Os li:iale
. Belu'een lr4edial cuneiform and base exernum Os peroneunr
of l'' and 2"dmelaursals
. Projecusbelu'een the J'' and 2""
meuursais
. Spindle sbaped- upcrs disnlll
. Usuall)'fused to disral lateral cornet
of Oe medial cuneijorm
. Freguencl'= 1.2 - lUV"

Os Sustcntaculi
. Poslenor aspecl of sustenraculun tqli
. Rarel)'a d:mnO bone (0.47lo)
. Fibrous or fibrrcanila€tnous connection lo su-stentaculumtal:
. More conlnloDul ntales
. Freguenci'= 2 - 3o/o

209
 O s C 4 l c 4 n c u sS g c u n d a r i o u s
. ltllen'al b€l$'een anleromedial calcalreus cuboid tuvicular. a.lrdlread of taius
. l,ocated dorsal
. Freguenc-\'= 7 - llo/o (male): 6-T0/o6emale) 7
\

Os Cuboides Secundarium r
. lnren'aj betq,eencuboid natrcular. ulus. and calcaneus
. L,ocated plartar
. Process can connect to cuboid
. Frequeno'=l-3"2

Os Talonaricular Dorsale
I
.
.
.
AK.A Os Suprrruuculare- Pirie's Bone)
Locared Dorsallv an T-N-ioinr - near rrridpoilt
Frequenq' - l5oZ tmale): ) )7o ffenvle)
r
Os Intercunciformr:
.
.
L,ocated dorsalll' trenreen proxrmal segmentsof inrermediareand nredial cuneiJormsand rnvjcular
\\redge shaped
t
. Frequenc-\'= Iozi,

Os Cunco - Metatarsale - Plant:rrc

h
.

t
Located planurlv beru,eenl"'rrreularsai and nredial cutreiJontr
. Frequeng\'= rare

Os \/esalianum
. l
I-ocared.iust proxinul to t-lreruberosin' of the 5h nreutarsal
. Musr be diflerenriared fiom ossifung apophvsis I
r Frecuenc-r'= rare

Os Subrihide
. Planar to medial majleolus Os trioonurn
T
. Round or anguJar appearanc€ ,rr",..,_
. Frequeng\' = l%o 'lalus
accegsorus
I Arromalousos
IAIDCAIL-ar|eum
l
Os Subfihularr

t
. Suslenteculum talr
Planur to lateral nralleolus
. Round or comnur sbaDed Acessory navicular
. Frequenc_r= ? Os tibialeexternum
Processusuncinalus
Calcaneus
secondenus
Os intercunenornE
a)G
T
inlermetslerseurn
Os peronr.'rni i

Os versahanumpedrs I
l
I
210
T
t
 OSSIFJCAT]ONOF T]TI BONES OF THE FOOT

Bonr Priman'Ccnrer Secondan'Center Fusc

Tibra 7-8 \\,KSlnUautenn€ hox.. beforebirth: Disul 3-12mos
Fibuia 7-8 rvks rnu-aurenne FYox..3-lrrs: Drstal9-12.5mos
Calqureu: Jro mo rnlr?ulenne Pos..6-8rrs l 4 - 1 7r r :
Ta]u-. 6tlr mo rnu-auterine
r.\aucular 3rd \T
Cuboid Brnlr - 6 mos
Medial Cuneiform 2ndrr
I nt erm edrate CuneiJorm 3rd rr
Larcral Cuneiform lst rr
Meuursal l lOth q'k inrraulerue Base-3rd rr I 7-2()rrs
Mcuursal IL In.l\ 9th n'Ii int':rurcnnc Hcad 3-4 r: I 7-2Orrs
Meraursal \u lOth rvk inrnurerine llead 3--l rrs I 7-20rrs
Proxrnral Phalanees I I -15 n,ksrntraurerine Base.2-8r'rs I 5-I 8rrs
Middle Phalanees vanable. afier l5tlr n* intrarnenne Base.2-Srrs I 5-I 8rrs
Drnal Piulanees 9-12u'ks rnrauterine Base-2-8rrs I 5- I Errs
Sesamoids rn FIIB 0-12rrs

DIGTTAI SURGERY

Anatomv of the Exensor Apparalus of the Toes -,EDL

a) the EDL rendon
I dn'ided ar the level of proximal phalanr rnro
three slips
2 a nriddle slip inseru inro base of dre nriddle
phalarur
3 medtal and larcral slips rnro base of drsni -I)."p
Transnrrrt
phalanr Inl ermtlatars:l Li6::n :rr
1. tlre combined EDB and EDL rendon has no
inscruon at the base of tbe proxmal phajanr

b) EDL is held rn cenu-alposinon on l}re dorsum of t}e roe bv a fibroaponeuoDc srruotue exending from
]r4TP-iorntto PIPI
i. the proxmal segmenl is a sling-like $ruour€
2, uraps around the capsuleof the MTP joinr
3 inseru at rbe;uncoon of tlre planur plate. deep uzrrlsversemeuursal bgament and flexor tendon sheat_h
4 thus. tlre EDL tendon is firml1'held to the plannr rpeo of tlre proximal phalarui nor t}le dornrm

c) enensor u'ing or hood is disal segmenl of exersor appaJ-anx

l. provides in^senionfor the lumbricaies
2 lumbncai muscle Fsses planur to t}le deep Lrars\:ersemetaursaj Lipamentto inqen rn1glbe e\lensor
hood

Errrinsic Muscuiarure
Exensor Dig:torum Longus
a) origlnar: fom anrcnor comFrunenl of tlre leg
b) passesbene.athe\lensor reti:raanlum and dnides rnro foru slipe

211
 c) al $e MTP joint- gn'es ofl erpanson<
-pro-nmal enenstons arc r'erucalJl orientd-
{rstai exensoDs are obLque fiben and provide inseruon to the lumbricales
d) in:<ensal the base of the dlsul phajanr
gatt
;j cra?les a dorsillexon' force al the nreuursophalangeal-ioinu in surng ph:se of
f) also doniflexon a'tthe anklelotnt

Fle.*-orDigltorum LonPu-'
a) origrnares rn the deep poslenor compannlenl of fte leg
b) di'r'ides irtto four shps in t}e secondlaver of tbe foot
.i each rendon passesplantar ro t}e MTP-rornt and insens rnto the drsal phal:mr
d) four lumbrical muscle oriprnrtes from the four lendonoussbps medrallr'
.j the gudrargs planue in-serrsinto it's lateral pomon forming a conjoined tendon

lntrinsic Musorlarure to rhe Lesser Diglts

Flexor Digrtorum Brelrs
a) origrnares from plartar asfrct of cals,neus ur the fim la),er of the foot
b) passesplantar to tre MTP-ioint
.i at 1}releyel of proximal ph:janr rt split-sto allos'the long fleror to pass|uough
d) insers rnto the base of the middle phalarui
at the
.j f'nctions ro planurllex rhe IPJ along u.i0r the long flexor. lhs cau-sesa reuogra& dorsiieson
MTPjoint

Dorsal Interosset
a) are bPeruute muscles
b) origrute fiom adjacent sides of correspondrngmeuursals
and in-sensmed:aUr
c') rhe-firs dorsal inierossei ongneres from ad-lacentfirs and second nleuratsal shafts
rnto the second toe
lesser nreraurs.alsand
d) tle r€maining inrcrossei orignnarefiom the adlacent sides of tlre correspondrng
i1-serr Laterallr into tlre bases of prorrmal pfialanges rwo. t]uee and four

Plantar Interossei
a) r-rnipenrntemuscles
b) originare from planur mediat aspect of mennrsal shafu
.i inin mediallliinro the third- fourrlr- and ffih digrts ar the base of the proximal phalarur
nreutarsal and ttrsen-'
d] ilre flexor digiti quinti brerrs onlunares frorn tlre lateral planur aspeo of the fi-flh
lateralh' into base of pro-ximal phal:rnr of the flflh digrt

Quadrarus Planue Muscl e

a) origirreresfrom infenor surface of tlle calcaneus
b) insens tnto the lareral aspectof the FDL tendon
.j provides ponimal subilin'to both the lumbricals and FDL
advanuge. adductovarus
d) snighrened out tre medJal proxmal pull of rhe FDL: f ir loses it's mechanical
ffih toe u'ill result

Lumbncales
a) four in numbcr origlnaring from tJremedial asPectsof tbe FDL tendon sllps
e>.rensorhood
b) rarel planur to l].teu-art-s\'!€rsemeuursa] ligament and tn-senmedialll rnto tle
c) tlreir funaron in ga:t is tleoreucal al presenl

212
n-AIL SURGER'!'

,.slrn owrllrng po:leior s)<ur

Tota rr&:ror n:face of postenor:jiur folc
I
.i t' eponychirnr
ortrcles
nail plate
ne e:rd of n:,il
hy'J,ortwharn
nrnace ol nall

narl bed

n^a.iimatn:<
di.tal Flrala.u.r

lttail -4narornl'
Nail Plate
Djrrded urro tluee areas denved fiom tluee dilferent gernriruJ sites: dorsal nail plae - from uper nail root
nutnx
rntermediatenail plar - from lou'er nail lnarl-ti
venrral nail plate - fiom t}e rnil bed

Nail Bd
a) rs loared underneatl dre e.rposedand concerled ponions of the rniJ plate
b) consrss of a germinawe laver and a densederml.
c) tlre deepes pan of Oredernris is fused to the penoseum of the drsal phalam
d) tre concealedporuon rvherenaii gmuth bappcrx is caled tte mrtrir
e) tlre ourer hrrur bf the marrlr u a semrcircdar u'hjtish area called the iunula
f) rhe hlponvchium is a thickcned frcruon of cpidermis undcr the distal fiec edge and is continuous uith thc
germiruu\e la1'er of the nail bed

r-Nail\l/alJ
a) folds of epiderrnison eit}er side of t}e nail and covers tbe rrail proxirnall'r'
b) at the pmximal nail fold tlre lrornl laver spreadsonto a free surfaceas tre eponvchium or cuucle

Nail Groove
a) it is a furrou'between tlre bed and t}re rrall
b) the epidermis loses all of its lavers here excep tle germirnul'e la1'er.as it continuesonto tlre undersrface
of the rnil plate

Ilatnxectomies
Indrcauons: Contraindrcauoru:
a) onvchocnP oss (tngroun) a) rnfeaion
b) onvcboml'cosis (fiugus) b) rzscular compromtse
c) on1'chauris(thickened)
d) onvcbog4pbosis (dvsuophic)
e) on1'chohll'sis(separated)
f) rncun'arednail

213
 I
Pafiral lrCam>ieoomr' - Chemical
Phenol and r\lcohol techruque
I
a) done un&r local aneslresia and a digiul lounrguel
b) rngroun nail border is H
c) English Arn'il
d) &e nail qrianle
giiner
is
is used
removed
ttith a sFn:ia or Freer elevalor
to spht the oflendrng edge I
e) Iutrix alea and nail bd are currened lo rentove debns
f) the poserior nail fold is currened lo remove anv debns
g) phenoliz^;on rs pcrformd (8T/o prre pbenol)
prolea ad.iacentussues'it-hoirtmenl (ie-peuoleum-ielll':betadineoinmrent)
I
I.
2. apl-r'phenol on conon suab for 30 sec tnten'alsx -i
-1. aplv alcohol on a conon suab to qash tre phenol
4. dresstoe urt-b a dry serile dresstng
I
Sodjum Hvdroxide tecbnrgue
a) described firs bv Travers and Ammon in 1980
I
b) done rn a similar fashjon as the Phenol & -Alcohol techuique. but uses NaOH l(P/o and neurahzed rvith 57o
aceric acid
c) suFpos€dh' rs more predictable. hipfr successrate. lou recurrencerate and less drairnge 'rritlr f:rser healing
ume
I
d) NaOH is applied x.1r'n-herefrom 3 se.condslo 3 minutes until *rere is risible coapulation of *rc nail bed
capill:rnes
e) afler cdrerncludessoak-c'\rithsrl:ne and dilute aceuc acid for 20 min/3s da]'for 7-10 davs depcndrngon t}te
dratrnge
I
Conrpl i cau'ors of pnial chemi cal nralrixeo omt es
a) recurrence resulung from.
t
l. rmproper appbcauon of t}le cbemical
2. nol eDoughcurtclulS€
3. dilution of the chenucal secondan'to bleedtng
4. impropoer remoral of t}re rnil and mauix segrnenl
b) q's forrnarjon resrlting fiom:
I. urnggressile matrix remoral and carne4'
2. sand allon'ed beneat-bthe poserior nail fold
I
TJrermooulerr'
a)
b)
descnbedt^'Kobak in I980
done under local ane$lresa and a distal roumiquet
I
c)
d)
e)
nail border is fre€d and oflendrng edge cu st'jt} rnil gbner
rhe rnil spicule is removed and the rnil fold is currened
hand held disposasblecaulery loop at temp. of 2200 F is used for one or t\r'o seconds
I
f) afier care ts the sanreas for Phenol & AJcohol tecluuque
g) advantage= no c:ltr.slicchemicalused uith this technique

ElecrrodessicarionPanial N4arruieaomr'
I
a) descnbedbv Vernon rn 1938
b) i nvoh'ed u-sing eiecrrocatuen' hr{recal or urut
c; needle of blfecator insened under rhe posenor nail fold
I
d) 11reunit u sel al 50 imd hrfecatjon s psrformed in intcnals of 3-4 srconrt<.until all the matrix is desuol'ed
e) Kerrran and Klamus reponed *us technrque to be safe and eruemell eflectjve
I
I
I
214
t
-
Tb ta I oz ZlPa r ri a I A4anl xec to m1-Pr o-cE
di r e.<

WrnoprradPanial Matruleqom'r

m
a) descnbed n 1929
b) one-fourt} rnch of the edge of the ./ t-r \
t'a l rl
nail a-longsrith mam>i and nail -r-l t t
a - '

bed is rentoved and currened

| t
N..- \
c) done ria a linear rncison do\rn lo
bone i=\
I t
t
\
\ /
f
t

d) a srip of t}e nail fold is removed

e) nrargiru are undermtned and the
incision is closed qrD surure

Fros Panial lriarrixeq om'r'

a) descnbed in 1950
b) a rrrodif cauon of t}e \\/inoprad
procedure
c) u-ansyerseincision for bcner
visibiiiq'of Oreunderhrng num\
d) initial\'djd not use suturesfor
g-Fi
closure
e) follon,-up snrdreson botlr above
proceduresare prornistng
It the flap created could causearzscular

"ff
necrosis of t-beup
g) t-betrchnigue could be moditred br

h
"I'-slraped irri son
uslng s

\\tumq' Total Manlresom]' (Acisonal)

a) fi.rs describ€d in 1968
b) a sprula s used lo open ry Ore rt.ril
distalll'. n,orking proximallr
c) the nail is renroved rn loto
d) the poserior naii fold is bluntll'
elerrted
e) tle nail marbi u seorred uith forceps
ald reruovedir toto
f1 rechniquedoes not pmvide fi,rll
el;postue to tbe nail marl\

215
\\?rime1-Toral Matru(i! om\
a) descnbed in 1968
b) skin rncisions sinrilar in destgl-t
to t}e Fros tech-nrgue
c) r\r'o paraUel inosiors are made
and flap@ oPcn
d) dre nail is rettloved firs and
\Lr/---
the matrix follog's
e) the stcn tncisioru are closed
j i I
's'iG suture
ft tlds tecluuque Prorides good
e\-posureto lhe mamx
g) iou'er recurrence rarc comPared
to OreAcisional techniquc
G,
t 1 \
\ \
Terminal Srme TouJ h4atrrreooml \ r
a) ntos radical Procedurefor
d.rsuopluc nails
b) removes the entre nail nail uall.
and rnaru
c) close defect u.ith planur s}an
flap afier rese€unBthe disul
half of the drsul Phalanr
d) acqured the name Slme becauseof
Ore planmr IlaP
e) dr,sadrznuges;
shonens the roe
porendal slough
createsbulbous terminal mrb

Zadili Toul lr4auireaoml'

a) uas firsl descrr'bedb1'Q:enu in 1887
b) tlre operadon renlovestlre nai-l maru and dre nail niilrout shoneni:rg tlre drsal phalarui
c) rhe eponl'cluum is ercls€d and tJ}eslnn flap is advanced and surured
d) rhe procldure shouid nol be done rn pcrrentsn'ifi P\D or uncontrolled diabetes mellirus because of
complicadons (ie-sloughrngof tlre flap increaesedrisk of infection: delal'ed healing)
e) Kaplan modified thrs procedure bn,renroung the rnil bed conrpletell'doun lo terrninal Yfralarut
lateral rnil borden along uith the
I O,tens modifred the Kaplan rechrugueremovrng the medial and
endre nail bed

216
ITA}1h{ERTOES

F,artulenoe
a) mos conrnlon digluJ deformln
b) the pror:mal phaian"ris dorsiiereC and the mjddle phalanr is piantarflexd
c) tlus rnal buckie the N{TP-iornt and make it promrnent planurh
d) primarih' causedbv blomechanical malfi'ucuon
e) shoesplal a role ln formauon
fl long secondtoe has a lendeno'to develop hamlnenoe defornun
S) rnv present uitlr heloma occumng at the PIPJ or DIPJ levels
1.t radrograplucallv one seesa doniflexed pror:-rnal phala;u qitl flex.ronof tlre nrjddle or nriddle ard disul
phalzmges.
-[utv seea "grunbarrel'' sgrt

T\p€s of Hatffnenoes
a) Flexor Subilizauon Hanmenoe
t. usualll' occurs il a prcnaled fool
2. usuallf in lare srancephese of ga:t
3. pronation causesh1'pcrmobilin' of the forcfoot
4. the flexors fire earlf in gait ro s,:bii:ze a hlpcrmobile forefoot
5. this causesoverpou'ering of the interosseousmusclesleadrng lo harnnrering or clau'irg of digrts
6. u,eak i,nrerosseous nrusclessecorrdan'to a rteuropatltvu'ill allou o\/e{po\r'eru19of tJrelortg 0exon
7. ilre mos corunon etiologv of hammenoe-'

b) F)exor Subsrirurionllammenoe
l. occurs rn tlre suPrnatedfoot
2. ocrurs rn the late sance phaseof ga:t
3. there rs su-aigbtconracoue of all lcssertoes
4. usuallv tlre mcePs are u'eali
5 deep ntusclesof the leg tr1'to substitutefor t}e rrceps
6. tjbialis posenor-FHl. and FDL fire carlier and longer causing contftrcrureof all lesserdigtt-r
7. a hjgb archedfoot n'ith contraoed djglu is tbe usual presenrarion
8. rhe lqrs conunon edoiogl'of hammenocs

c) Extensor SubsrirudonHammenoe
1. occrrrs rn srrrng Phaseof gatt
2. rlre EDL overpowersthe lumbrnceies
3 seea straig}t gorsal contracnue of the MTPioint
4 occuts drring proprlson suing pha-se.and heel ff)nusl
5. deforrun'is demon-qrated['haring the patient dorsrl]ex t]re ankle in a non-u'eight beanng siruauon
6 in anrerior pes €\'us foot qpe, passjve prull on t}le EDL tendon is crmted tlus causesdorqifle)oon at
rhe MTP joint and fnssive conttadlne et tlr DIPJ $'tbe fle.ror
'i
also occursin ankle equirus deformin
8 in periplreralneuropothl' and neuronruscul:udiserses-t}e lumbricales are a-ffeoedand tlre EDL gaiff
advanuge leading to an e\leLsor substjtutlon pbenomenon

CLA\TTOE DEFORMTN'

Clarrroes
a) flexion of rhe midde and disal phalarges on the proxirnal phalarui
b) most ofien involve all tlre lessertoes including the hallui
c) usuailv asscrrareriu'ith carl-s foot and neuromuscularcondidon-<
d) alnz1's assoclaleduitb dorsal contracrureof t-heMTPlornt and planur @ntracruteof the IP-l's
e) ofien seebypo'keraross and Fmiri rneuursalgia beneat} tlre memarsel heads
1) earh' su]gesma]'be flexible ald sraighten oul $itb tbe prsh-up tesi

211
 I

a)
;;
lare sl3ges &e tnrerphatangeal-ioinusuill flex
,-,"' n?a"rgr sho.., dorsiflexed posiuon of the
nhen lbe mcull3lsels are loaded
proxmai phalau and planurflexed position of the middle
I
i)
arrd ciisul Phahnges
a
''gun barrel" sgrr nrlJ be seen on DP mdrograph
I
Nlallet Toe
at disral phalarut is lloted on dte rtriddle
b) no im'olvement at the
ai aqqooated s'rth a long dgit
PIPJ
pluJanr
I
d) esrension of tbe joint is limited
.i difficulr 10nlatt'rrlll redue if )ong sunding condiuon
f1 x-rav seeDIPJ conracn'lre n'it-h e\ident
ls \'ra resecuon of rhe
gun barrel sgn
head of $e middle phalanr
I
il surgcal correcrjon
il ma! ncea ro relcase t1teplanur conrao're ria tenotoml'
i)splinrincorregedallErntentfort]ueerveeksinsurgicalshoe
and capsuJotoml'
I
I
FLOATING TOE
rhe ueiglrt bcaring srface in sUnce phasc and
a) a conditioltin s'hiclr one or tlore lo€s fail to pgrchase

b)
u'alking
caused tn. a faiiure of tlle fleror rnecharusmto funoion eflecuvelr
I
rensesrhe 0exon and planur fa-ssa Niuch sabilze the prolmal phalart\ on
inormar!. rveighl beanng
I
;;'
to load tlw srrand of planur fascia and
rhe meul,.lr,"J hqrd failure of rlc ml ro load rcsulrs rn failure
fleror caP. Resulr is unsuble toel
rarrogenicalll'shon or excessivesll'eleYated
dl ort., *r..s inciude a shon nreurarsal:brachlnrcrararsia.
of tlre MTP joint
nteur'"rsals. seycre hatnmenoc or clauloe deforruq--
e) -qror."nr is *re loss of t}le inrcmal
cond-r,lecromres.rrreutarsal hcad
cubic
resectjors.
conrenr
ard u'ith
dislocaUon
from u'irhin
reseclton
rhe MTP-ioint: this occurs $'ith planrar
of proximal ptulangeal !a5s
I
is aimed ar *le caus€ of rhe 0oaring roe (ie- brachrmeraursia lengrhenthe nretatarsal: ba-se
fr ;i;;-"-.rj."
of proximal phalarui resecrion qrndacq'I1')
g) sutitl'i.'g arthrcdess of rhe PIPJ. K-\'ire flrauon and exensor
of floarrng toe
rele'ase I
i,l surgcal correcdon
(ie-brachwreraursia)-if the causeis relatedto chronicadhesive
.

.
basedon Oreca'-seof tle flcurjng roe
crpsular rclcase along sirh arrhrodesisshould be auenrped
if the enolog. is an ele\ared lesser meurarsal. tlren a planur drsplacement
oseoloml should be
I
.
Performed
o6er oFrols for floating roe qrndrome rnclu& srndacniizauon
and V-Y adrzncenlent
t
L qrrdacn'li'rton
. salvtge prcrcdure secondan'10pnor sutgel-\
je-resecllonof the base of the proximal phal:rnr ur$ resulunt floating toe or floppr' toe resecllon
Of mennrSal hc"d ur1|i lg5plrrnl flOaUngtOe
I
. loss of toe ptrrchasesecond:rn to iauogeruc causes
. contraindicarronsto srndacn'iizarion
infeoed inrcrspace
I
macerated lnterspoc€
. thjrd and fourrh rce s-rndacnlizarion is conu-aindcaredsinct trese digiu lie in bet$een
medial colu.lurs (tlrus. secondroe rs s-rndacl'hzed to third tcr ald fourt-b toe to fifilr
tlre laeral and
toe) I
I
I
218
I
2. \/-Y adrancement flap
- ---->a - -
salrage procedure for tle correcion of iarogeruc floaung lo€
>prrducssa digt \\rt} no acx\,3ocninerion oi plundevol;
>good reponed cosmencresrll

\
-ts\--Fff\
ffiro\ '-\
)*\ i

AR TIIR OPr-ASTY (of PIPJ)

a) indicatr.d for llexible to scmi-rigid dipruJ dcformiq'
b) Oredigit is aFproachedthroup&a hnearor semi-ellipticai incjsron
c) tlre incision js acrried througfr sub-cuuneoustrssueto the level of rlre EDL rendon
d) a rarsvesrse lenolomv rs made at the leveJof the PIPI
e) mediC and lateral collateral ligemens are rncised
f) tlre exersor tendon is reuzoed pro>rmalll
g) tlre head of tlre proxnal phelan-r u resoed
h) Kelikian push-up tes is performedif deformin' is not reduced
seguelrtialreleaseis pcrfomred rn the follon'ing nuutner
l. erten-sorbood resesuon
2. ertersor lendon lengrhemng
3 dorsal capsulotoml'
4 piintar capsule release
5 anlrodess

ARTIilODESIS OF THE LESSIR DIGITS

a) converls the toe to a rigld lever
b) rndrcatedu,lrereintrirsic muscle subi-lin'is conrpronrised
l. lack of MTP jornt s.abiliq'
2. senu-redrcible or non-red:cible conu-acnreof the IPJ
3. hlpcrkeramtic lesor overlyng t}le IP_iornt
4. u-ansr,erse plane deformiry of disai aspecrof t}e toe
-r. clau'toe deformitl
6. abnonnall_vlong tc
7. to neutralize the long flerors and e.xen-sors
c) prrcedures
l. end-to+nd fi.rsion
>done via a gandard artluoplasn'rncision
>iP joi-nt fued from sofl ussueanachmenu
>canilage from headof prorimal phalar-,'-res€oed along uitlr t-hebeseof the middle phalarui
>K-slre dnven through middle and drstalphalarngestexiung duouph up of roe benearhthe nail)
>rc:ected surfaccs di grcd
>K-lire driyen acrossste and snbi}n'is checked
{.015 K-q'ire car be nsed if nor crossilg MTP-iornr
>0.062 K-rvire can be used if crossrg tbe lr{TP jornt tarnrhrng smaller n'ould break)
>mainnin K-rr'ire fixadon for.14 lr'eeks

2. peg-in-bole fusion
>mos opimum procedve for fixion of a digit
>Frodrces significanl shoneningof the digit
>.tifFcull to perform
>dorsalconexof phalangealpeg lefi inrao ro pro'ride subilit\'

219
 \

>gocd bone sock is neededto pcrform

>althougfr stabie.needsa-K'rnire fixaoon
I
I
3. spike-in-hole fu-sion
ffiiEi!N I
>r3rne as peg-rn-holefusion but the proximal phajanr is frshjoned rnlo a spike
>dorsal cone''i of pha-langealspike lefi tnuo
>no gt?al adrznuge over ilre peg-in-hole fusion
I
CONGENTTAL O\'ERLAPPING FIFTR TOf
I
a) definition. &formirl' oco.rring al &e frflh lt{TP-ioint
s\lron\ms = overriding fiflh toe
h-r'pererrersion of the fiJilr toe
elerated contraoed rarus of tbe fiilr toe
I
digin quinu rzrus
b) etiologr
l . usualh' congeniuj and bi-lateral
I
2. less cornntonlv unilateral.traumadcor larogenlc ln llanue
-1.mcidcnce rs eCualberg'eenmajes and females
4. firee marn comlrcnens of the deforrntn
>-artrll'ctjon contmfl ure
I
>dorsiflexion
>exernal rouuoD
c) clinical apfEannct
l. the toe usualh' aPPcaEsmaller,
fl
f, ft, I
smaller. shonenedand
"PoddieshaPed"
flanened or
2 supn-addrcnts: the ffih loe over
the foun}
3. infra-adductus: tle fiflir loe under
I
flft
the founlt
d) deforming forces
1 dorsal and medial skrn rs usr:all)'tighl
2. in severe ca-ses. the skin of tlre web spacecan be contraned as u'ell
3. medial collateral ligament and
I
dorsomedial MPJ caPsrle are
shonenedand nght
-1 rhe EDL tendon is conu-aoed I
e) consenutive lrezllmenl
l. usualll' resen,edfor children or for &formln' t}nr ts not longstandng
2. srerching and su-apirg urro planrar0exjon and abducnon
l) surpcal ucaunenl
I
l. con-sideradon&pends upon Oreage of the p€Denl and lcradon and sevenn' of l}re deformin':
>slon plaa'to lengt-bendorsal-medial sliil
>tenorom]', tendon )eng}eniag or rcndon transfer
> dorsal-medial caPsulotoml'
T
>osectom]'
>srndacn'lizarion of the founl and fifi.}r toes
>amP:nrion
t
>a combirnoon of Procedures

I
220
I
g) hrsorical surpcal Proc€dures
-_1.-Ande*on: -remoiEl
Of a-Flantar skin'rvedge- dorsal-V:Y-shn-plasr-. lengnhening-of-t}e-EDL-tendon---
fifli nreuursal iread resecrron irncjslciacn'hzalsn of tlrc fourth and fiih toes
2. Burler: dorsal raquet incjsion sitlr a planur handle. enensor lenolomv and MPi capsulolom\
3. Durnes: dorsal Z skin plasq'. exlersor end MPi capsrJotomr'
4 Kaplan: planur sl,enn'edge pla$l-, eilensor lenolom\'. dorsal merriet and iarcml N{PJ capsulotoml'and
prnaj po>amal Phalangeaoml
5. Kelii,ran: sndacnlization of the founh and fifih tcrs and a proximal phalangeaoml'
6. Lana.oums: stainlv s s:gual plane correcuorL tl tnvoJvesan MPJ capsuJotoml'and a uander of rhe
EDL rendon rluougfr a drill hole placed tjuoupthtlre necirof the f,flh memmrsal
j. l-apridus:dirison of the EDL tendon and u:insposiuon to the d:stal end of tlre abduoor digiu miniru
tendon
8. \tr/ilson.dorsalV-Y slo-nplasrvand enensor lcnolornv and elonpnon
h) pos-oPerauve czlre
1. conrPressslvedressrngl'
2. ObSen,eneurorascular SanL.
3. toe splinred 4{ u'eeks to nxrintain correcuon
i) compiicauons
1. recurrence
2. dehiscence
3. shoneneddigrt
4. insabilil'of tlrc fiflh MPJ

POL}'DACT}'LY
Definiuon: prsenc€ of an acessory'-supernumeral or errra drg:t
a) velY cotrullon congelutalartotrralr'
b) rnal.prescDl as a bypoplasuc digrt uitlroul osseou-(strucnrteor as a firllv der,elo@ dig:t
c) can be either prean:alor medial to tlre second meurarsal (theaxis of the foot) or posaxial
d) crn fsrm porr of a sudrome or r.n presenl as a norls\:ttdromancor isolated deformin

Classif cauon
Posr.axialpolr dacqrlr' (fiflh digit drplication) accordrnglo Temumr' & McKusicli
Tlpe A charaoerized b1' a full1' de'r,elopedacccsson' digrt ilrat anicrrlates s'it} the fifi-b nreuursal or a
duplisaled ffih meuursal
Type B: charanerzed bl an aeessory dipl uitlrout osseoll( subsance
this classrficauonfails ro addresst-berange of forms benleen digit der,oid of osseoussubsunce and
complaell' duPlicated
dtgt ;rr"rccr
-----'-*
-;Fc-r-,-

I -)ssrrr
, r?vr I
I rF6-
F,rr-,
i f
t I FTvpj
pg,<c::r.rv-a ticryEr-.sic J-)^t;,g, Ltr-r,
l
I i_ i,rc*_J-rn
| !-rrp. r
Lr,twnc 3c'<.Eiti

22t
 -
Verur-\\; aLsonClassitrcation of posuxal polvdactl'h'
ba-seciupon degree of dupircruon lorm leas ,iiferenuated to the mos dlflerenuated:sofi ESSUC

,duplicauon-u'ide nreuursal lreadT-nreurarsal.\'-meuursal and corttpietedupllcauon I

\

c
I
*,,
Y 9 '
-c
A -
rl fi* nF EA
I t fI
!Lr D IJ, ilt'i H 0 Jl t-
(.J '(
;-; fr\J?' ilfr \r', t Jt l
( i
tl r{ l I(
[v|
l i i i
I /
/tvt{ t /
! )
V
I
t . - (-) u '{

rride met T-metaurrsd \'-rr-reutarsd complete

L^^J
ll@
duplicauon

Pre-a\i al Pol I'da cr-r'11'(frrs dI glt dupb cat on)

rarell' tnvoh'es ilre foot
nor u'ell documented comparcd nith prcaxial polr'&o1'h' of the hand
Terntamr'& McXusick glaq<ifiedfour q'pes rn tbe hand:
Tfpe I - poll'daol'11' of the firs drgrt
Tlpe 2 - polvdaol'ly of a riphalangeal frm d:gt
Tfp 3 - polvdaol'|1' of a second drgrt
Tlpe 4 - poll's'ndact-vl1'

Biauttr & Olsson Classifcation (1988)

classi-ficarjon accordrngto radi omorphologrc ait erauors
ba-sedupon prcsirionof drplication on both tlre longinrdinal and translerse planes
a) longrrudinal: arr:rngen)enlis basaedon tJreduplication of a phalarrr or nt'from disul to provmal
and rs suMivided rnto fve q'Pes
distal phalanr
middle phalan:i
I
proximal phdanr
meraursal
utsal
b) u?rlsverse: arrangementindicates the number of duplicated ra1's u'hich are t}en numbcred trit-h
Romen numeralsmedialh' to lat erallr
pcrmiu classlfcarjon of tbe hand and foot
accounrs for special malformauorrs.sucbas triplurkrnglsm and muhiple duplicarlons
and in developemenlof a swgical plan
t
aids in accur:tledragrrosis

l
t
222
I
pREDISLOCATI ON SYIYDRO1\1E
Orsscr M TPJ 1nstahilint

DescriPtivc
. Parienlsusualll' middle age 30-50
. Aculeisubacutepai-nplanur mrpj(2"o mosl cottrmon)
. Parn disproporuonateto ph1'sicalfindrngs
. FL$or.\'of increlsed actirrtl-. Iratuna geroid tn-iecuon
. Sharp patn bruise. tluobbtng
. Gmpe-size lump beneat-bmrpj fuursal sac;
Stages: (not used clinicalll')
l. mjld edema-lendernessplanur/distal -ioint no changein ahgnment
II. moderateedema
Ul. chnical derraton of drg:t- loss of loe purchaseurti u'eipfrt-bearing

DifTcrcntia.lDX:
. suess fraqure . spovitiVcapsuJius
. hammenoe . neluoma
. meBtarsalga

lmaging
X-ra1-findings
. lon8 2* nrel . a.heredMTPJ congrurn
' hlPenroPhlc . + dran'sigrr lverucal $ress le$)
conex of I subilue met
involved trel 2. hold prox phal parallel lo nlel
3 u-alslocaredigrr rn sagirtal plane
gy€ter tlnn -507r-?osirive resr
Bone 9att
i inc. upake rn ars:oeran plraseindicaung urlamnralon'process
A4Rl
l.edema along d:stal slip of plantar fascta
2 thickeni:rg of planur plate or ruprute visible
3.capsulosror"ial ioint eflusion

Consen'afive TheraPl':

) reduce patn

i SplinVsrapprng
Meuursal splirt pad
Cross-overrape method
Subilize prox phalanr rn pl:rntar duecdon
Can be used as a diagnostic tool
i Medrol dosepackrNSND

Surge4'
*Z' **Bo$ t}le Weil and Helal osreolomv are
> lengthening of EDL
urilized to shonen rhe meurarsal and ro allon'
i e$ensor hood recession
jornt decompressoD

) K-qire f,radon in overcorrection

> Pruu4 planur plare repair fronr planrar rncison

) (obiigue at meurarsaj neck from dorsa.l-pro.r:mel

Helal oslteolom'\' to pJantardrnal)
i Pos-op spLnt to maintam correcrion

223
 t

BRA CH)'\'ETATARSIA

l)cfinirion:
plrte lyirenmore l}nn
A shorl llrpopilsrc lttctLursll due to prclt:llure clocureof the eprpirlserl
lite cond:ttonrs CalledbraCituretOprfr
one lnclatarstlts rnr.Ol'r'ed

Et iolog-r
. conlenllal
e de'r,cio;:tttenul
. tauL'L' enli
. uaunlau(

Assrriarctl clnl't'nital anrtm:tlics

- l)ou-n s Srldlomc
- I u r : t e r ' sS v n c i l o r n c
- sickie cell :rnenril
-
-
-
.albnghr s Congeruul Oseodrsuopht
pseudohrTrotltlroidrstn i pseucio-pseudohrpotllroi ci srn
;rclronrvelitrs
I
- l l l \ o s r l l so s s t f r c l r t r :
- cjvqroPhlc du'lrfisn r

Clra r:rctcrist ics:

I
uniiareral or biiateral
I
r l::l lcmaleto tnaleratto
r
r ,1u t.t'6'13u]rsal
nlosl conlnlon b
-1-
r ttsttli)r' hrcolltes cvicient btrtu ccn :r-lcs I :

Clinical l)n'\('nl:rl;{rn:
r slion. conrracted lo€ se€n clinrc:rllr
r siron ntctal;rrsalsctn radrogr'rphlcallr
. cosmctic ol psvchologlcal ctlnccnt )
. r)rcl:llrrsalgratr/c irrcleased ioad to ad.lacentrtlctatarsel:
r pllnw callus forn-retron
r fl<ratinglcr oI assoclated allrcred trtcutarsal F
r or crllrPPingtcr ciltl(cs
\
e\-lensot & fleror lencic'rllconlnlclule :
7
skrn conutcturc
)
Const rlativc I rt::tlmcnl:
r o n j t o t t c so l a c c o t n e d : t t l e d e r l c e s
r pcddrtrP

Suryical l'n'allntnl = Solt Tissucs

r \i -)' skrn plastY to relte\e lellslo'l of conuactcd shn )
r Z - p l a s r i e n g d l c r u n go f l o n g c x c n s o l t e n d o n
. lcnololnv of s)ron c\-terusorlcndoD
r \4TPJ carr<r.rlotom)'(ciorsal- nledial' lateral release r 7'
. secllonug of ciecp Lrdns\'ersc tntcrnlculurrsal I-tgutlent t

Suryical Trtatmcnl - Osst't.rus

( l l u n l \ O p t i o n - sl O t e $ o I e l t t e 6 U r s a l ; n r a t t c l a ) F
l. Osttriturnr'lengthcning;trrredures
J stngle mctatarsal osetrlomt sith inseruon of bone graft
] ccmt.rned len.s'}rcnrng and shcncrung nleul:rrsl cseotomre:
-' slide lengrlrenr-ogmeuursai csleololnles

F
\
1 1 A
?

!
 __::_Ti:11i*:il:Til:1f, :H.t-.newo'ascurar_compromise
- tesir \rdJ limrnr-.
- uruon/ nonunorn
dela'r'ed
- resorpoon ofboncgraft
/ collapsc

2 C a l l u sD i s r a c t i o n ( C : r l l a s t o s i s )

Descrint ion
. Technique rn s'hich bone leng:tbeningcarrbc acluevedb1'slos djsracdon of the bone calius tlnt forms
al lhe open ends of a surgicalll' oseolom:zed bone
. Firs performed b-r'Ihzarov on lou'er e.rrremiuesusing a circular exernal fixator devict.
. Bu;ed on dte lau of tetrsiott-suess
- lir"ine rissueu'hen drsrraoedslou4r'becomesmetabolicalh'aclr\:e

Procedurc
- iuratornicaldissection lo the level of bone
- incision and reflecrion of penosteum
- osreorom\ ",i#irr;;",;fl usororm
atIon
":l#T: :'fJ
= conicolonr\ - cul onex onjl to nraurhin endosleu:ri
--+ srud,resshou equaj successn'jth eirher rechruque
- placement of errernal f,ration derice
- rarencr
senodo- "ffi:Tl,".r"Jcor omlarddrsiracri
on
;T.fffi
= optimal latenq'-5 da)'s to 2 n'eeLc
- rate of Csracrjon (also vanes I'jt}t bone and paueru age)
= I mm/dal'rn -1equal Inctemenls
= according to Dizarov for tibiai lengthening
- djstracrjon stopped shen desued lengrhis achieved
- perid of ossificatjon al distracdonsite
- firatjon lefl in place until radiograpluc eridence of osseous urxon

A d v a n ta P c s
- no need for bone grafi
- no newovascular compromisebecauseall stnrcrwes are graduallv lengtlrened
- can garn more lengrh tran otler bone lengthening procedures
- caD graduallv lengrhen soft ussue structures(tendons.skin)
Disadvanlageq
- pln u:lcl lntecDons
- need comphant Pauenl
l n d i c a t i o n V Us c s
- brachlmeutarsia
- callus distraction Evans procedurefor pesplano ralgus
- lengrhentng of medial cuneiform for meradducnrs
- dbial lengrhemng or conection of angular deformin'

Ce | | u s D i fl r:tct ion Procedu rc for B rach vm et at arsia

- long:rudnal incision over afleoed meuursal
- anatomic dissectionto level of bone
- linear perioseal incision placementof errernal firator pinc
= 2 proximal lo o$eolom\'(l tn cuboid or cuneiform: I in meutarsal)
= 2 disul lo osleolom\'
- osleoloml'/comcotoml'
- closure of perioseum and anatomic lalers

225
 nu l rJ .9,L^r lnl !'rrr rl n n rn { . r r o n r l ' : r i r o l d c v r c e ( E B l t M N 1 - l o U n u n t e l l e r n a l f : - r - a t on
r )osl commonl
bcgin d:srraction5-14 dals ;nsr-operatir-elr
:/. tun) ]-l tttt,r:: l}-t \lit\ i..' - .l-'lllln ioti! icttUUt gal dlj
lunt oertcr Ft
seriaj raci-rographs - uill seenidjoiuccDlgap al d)sracllon ltrlauon
l r o n u ' egi h t b c : n n g r e c o l t t n r l n d c C
osseous consolidltron- tircn rentovccr-tcrnajfi.rato;

L f S SE R ] \ ' E T A T , 4 R S A I S U R G E R ]

H r s t o n c a lR e r r e n
l9l6 - lrlcrsenbach. osleolom\'3cm pronntal to MTP.tornt
l9l? - Davrs. headrc'scctron
rtrculursal
lq4() - Nlau: rcsecuon 61 uxigc
5-3pgz-eif,2l
l91S - Bolggeve surle as N4au excep prlonlred cisnJ
195: - ]r4cKeclcr. sub;lpUJ oscorom\'. telcsco;rd spiked end of shaji into;.rpital piece: sironcnirs
()slcol onl\
I9:i - Du\;nes. P)antarcon{riecomr
l9-iJ - Glannesras:scpdorrn sltonentngoslL'olonl\
l9.sJ - Rudcdge l( Green.rcntovaj ol nrctltarsalhsrd and one-drirdof t-heshafi
196-i - Du\;ncs. lllcuursal lrcadartluopla-qrand planral condl'lectolnr
l9r9 - 9() cicgreesto the shafi
Acicr''ltteoseociasi-q
19s! - \\:oif dorsflcron.osleolonl\ on dsr-alllct:ulnal shaft
l97l - Scrrilro oorsflcrory hrsc u'cdgeoscotolrl\ oI clcrzuonalcsuolottt\ procedurc
"\"'
l97l - lacobr" cl:lssic osteotott't)

-t
Ii t.
t
: r |
l lf l I .
|
I
l
I ifiL; I <<1.=-t-\ I
i tt r(Ji,._l t /
!: r6lMe:seicss:i r-d)7 {ia.tt:, l:cu (rrt3ul

i-_---t
leaGSl
i l
;:42 i?Y1::..=:',eir

[l r ,----
ii#'t-l
'1
95. )9C':13uvnes1
(___
'l
9€: /r'\'ol/l
'
(AuuEc?Faj{ F:r.l

'rlr-
Ariii
iLItri_t-l i
rQl-r r.--mn.,r

Eur'l hulc o.qrurL!n)

226
Neck oseoronles(mos commonJlpcrfilrnredcslcolonrtes for i-soLatedlliomas;
g) \l-osentomr'
I . jircrrnr ocscnir,xjureproceoun
ersepliineciuero "\\1n!s''
". a.liorlslree nrouon rn the sag:nd piane.bu suble tn fte u-an-.r
b) Oseoci:rss
l. fEnormed at the level of the meuphlscal necl:
l. Jrix lrouon In vagn:rland uzrtsvcrscptutes
3. high tncicknceof pseudoanhrosts ancinonunron
c) PNJOUxrcuuneous meupbvseal o$eolom\')
i . rr.-inscrse oseolotnv tlrroug} the lrsd of dle nrctauirsal
l. rns:rbilrtrand lrcal:ngproblcnusirlrrliulo ctsteocla-sts
d) DFWO (ciorsfleron' rvedgeoseotoml t
pcpulal prcreduretl-lathasspoured ntellr -stnlji:uprcreriure:

6) \'-u eoec
I . airc knorrn as tlreEanel u edge
I lrrureobbquc u'edeetlum DF\\/O allo\\.rngfor ltlcrutcedbclne-to-hone
conusl

Slronenrl-gosrcolonues(nJrennlonta nral l-r seconciln to an elonqrted rzthertlian a piarnrfiered nreuurrsal)

througtrand througltoseoloml nrth removal of the rved-cc
a ) cvlrndncal osrcoromies:
"\''
b) Cirevlon osleolom\'. simrlar to Jacoi-.r \\rcepi a second cul rs made prorrnral and the u'edge rs
rctrrovecj

Blstl ostcololtrte'
a ) E O r e x e n s o to s e o l o m v )
I srnrilarro tlie DFWO but cioneI -2 clrrcjrsurJ to tirc nrcLatarsal-currerfonn
iornt
I usLraiJr pcrlormcdto rcbeve :rn rsolarcdlPh
b) EOA {e\lensol oslemnhrolom\')
s;lntc indrcltlon-qa-( the exensor osleololttt erccpt thet n ts used u'hen subilrz-ationof lhe mcurarsal-
. - , l r cllr r r J l 'to t t l l I sd : s r r q i
ct Buckholzoslc<tlom\
L srntjiarindreuoru astte abovehtsai ttscotonrtcs
l. lrrorcob)rqrrca;rdprorrmalh'locatedaJ-rr tJiltndre crtensorostcololllcs dcscrihcdal'nve
I llre 11relcroblrqurtral]ou'splaccrrrclrlof a 2 7 nrnr corucalsreu for frrauon
..1nrcmseble

Tlre Gilifonrra (left cms ) approach

Pnnciple-.
a.1prrlonrr sugen on onlr'first- thrrd :lrd fifth ltreutursais
!1 urlJ pcrlorm surgen' on all submcuLrsal ltston-'
c) no sullcn on secondandfounh nter:urrsels

Philosophr
lls
haveindcy^.-nckttl
a) firsr and frfrh nrctatarsals oi lttotton(lnpl:rnat).and thus.ir;:re srgnifianl infirrerrcr
on Lirc sccond and founh meurursels

b) rhe rhird nreururrsalrs tbe mos in&;rndcnt of bronreclurnjcaland ol}er mei.anrsalinfluence

cj anluoCesr-<or anhroplasrvof tlre second and founh drSnuto remo\ e rerrogade planurfleron' force-.

Su-rgceJr€m)enl
a) subntel2 leson
l adciressfrrs nteutarsasldeform:n' fHA\'. htpermobilin. sagnal piane posiuon)
2. adrm3:sr-<or anJuoplasr_r' seconddilrl t rctror e rcuo_sra&forcr a tre secondN4PJ)
b t s u b l n e t . ll e s o n
l adlrr.-s fifijr mer:ursal del-ornun'lTeilor's h-rnion br;trmot'ii:n.. -.djucted fifi-h d:gt t
I anhmC:sis or anhroplasrl foun} dj g:t trtmor e rerograde force at *re foun-ir]ttPl t

221
 c.tstbmel 3 lesron
lesror,
I u-suallvdue to long tjrirci nreuursal ot larogentc ran-sfer
: G!) fErlonll aPproDn,ijle lliellltarsu Drt)ceour'

To Float or to Fi-r"
Ftcnung PhilosoPhr
a t lttcraursal urll ftnd tLsourt ievcl
(fibross) tvil prorrcieappropnalcand sable level
bt *,cjght h,calng and sofi rrsnrebrnciurg
c) decrca-se chance of rrander ]estolt

Fr.r'atronPhilosoPhr
lccelton
31s'h1 euess?qil piacettreutarsalat ciesrred
bl drllcttlt
c) Drcvenlnonunjon Pscudolnilrosls'clc

lnlrmUcllon
prcdileeronof Teilor'sbuntonoccursln l.I lemrle lo nralcr.:bo

I )T*,
i11 o5{.ous p:t}icxrn;lonrrcritr';xs of Tulor's hunton ltaveht-endcscnirtxj
3 i rouluon of t}re lateralplanur tr:bcrcletnto a laleral posltlon
br rncrused lnlernleuursrJ :m[u(
c ) urcrc-rscdlateral&uauon anglc
d) a iarge rounddumt*rell+hafr'd fifih nreulursalhead
c ) :rnSnrrcchangesmsulung lJrc\oslosL(fornratronat tne fifitr ntcratarrcphalangcai -lornt
n f l l r ct h t v e c o n l : i r t r o nns r l h r h c f i m ' J t r c ct . L t n tt h c t l l o s c o l l l n r o l ,
J t : r n r c o l n h r n l t r oo

Eriologr ta-.describcdbr Root)

a) abnormalST.JPronauon
b) unc-otnlrnstred forelocrtor rurrfcxlt larus rvjlh a prOrnUngfoot
l conpcniul planrar{lcxcdfifi}i ral
d) coneenrul ciorsifleredfifiii rar
hcadof rlrc adcirrcrorhallrrcr,srnto the fifth MTP tornt
c t ,ci,o|.,il.,,ccondiuon qruscdbl et^cnc.e6f l;.116r'crse

krd og:::plricEvalwuon
ArgJe: Bucklroiz & Flllat nrctlrod n'hich nles rnro consder:ruon $e lateral bo\mt prc\enl
1,.,r.r,.,.,-"r'urrs*l
s'itlun the fifih nreuursal
a l rcDrL:€nledbr. dre ang)ei*lu,eelr JonnedLr3t'rreell nvo ltlter -
>lrne dr.rul ad.lacjcnr and pqrallcl ro t-bemedial pronma.l surJaceof thc fiJrh nlcurarsal shaft
>lrnc brsccur.rg r}e long aws of the founh shsfi
llrcr'starssl
bl normal ralue is 6.'17degrees
crlltlrologLrcal rziue Ls8.?l ciegresftxurrondefonrut-r')

the Larenl bourng uitlun

L:renl De.atou .Algle: Bucklolz & Falla merlrod u'hich ulies rnto coluiderauon
the fifiir menrarsai
-
a ) IcprL-senledtn r}e angJefonued t'ulu een tl o lires
> irne brsecongrlre heaciand nek of rhe fifih nreuursal at tirc anicuiar surfacc
>1ne dra*l ad:acenrand paraUel ro tJremediai proximaj sutlscr of t}e fii} lneurarsal shafi
bt normal ralue is 2.61 degrees
c1prlroloPcal rzlue is 8 05 degrcs

22E
 I
I

lntenrreuuusrlAndr

ilrsronsll Revterr
"bunronene"
l!r39 - Harns & Darrs firs to dcscritre dclonnln
proposedsinrple l:lteraicolrdllectonl\.
l9-i j - l'loiirniln u-.lrLc|crse
os('olcrnl\ oJ ntctaulrsrslneck $ithcrutfivltron
-
l9-<3 Dr,ron. pronunenlfiflh nleulurs:-sllterd dueto splarrng
tn:nrlcnt cousscd of u'uirurr uidcr slrm or c\crsron jrtcrai cnndr )c and bursa
-
If-io L.clrcrcr:felt Tailor'sirr.rttton uzs due to threentecltattsrttr.
i . su;rrnuntcran' iritllr
2 rncrcasedtntcrn-retaursal anglc
: cross-leggcdslilng Frsllronltellor's.t
I !)-i9 - Br oul fi1t-hdigtt :ltd rttcuursa] rssecuonlo narrou foot
l!r-<9- DuVncs txrnronciueto tlrre rsr\olls:tncir€orrtnrencieci lltenl conciviccroln'r
l. br;rnrophr of sofi ussueovcrlltr-e nteunrsal hcad
2 congcruraljluidc frilr rtrcuursal lrc.rd
3. lareralbour:rg of rle fiful llleulnrsal
l96 l -.Anrbrev lareralcolrdvlectorrt\ hcedrescclroniil suirrncllestoncrised
or ntcl:turrs?l
i lrt g - ) aner': ix*e o$eotonrkr to dccruasctJtcIM ugle atrdlicad rclnodcbtp
I 9? J - Sg;lr)ano:ulked atnut lateralLrrurng of fifi} merararsal
l9?l - Gclcrrt:hrsc u'edgeoscolonl\ ustngiu-ngcau-'
I974 - Lach & igou: reverseN{rtchell
l9?a - Raplp;nn: Lnsr uedpe oseolonl\ and anJuoplases

SurgrcrJ.Approcch
blscd u;ron radognphrc rcrsrlrs lrom L\4 and legeral derrauonargles
a) htg-hl\4 :ingle:procedurcslrouldbe sonretlpe of txrsaloseolom\
bt lron:ul IM and lilgfi iarcml dcrietjon urgic, prccedureslrouldl-r::rn osteotonnal the nrcratarsrllreci,
c) all nontr"alangles.rf tarlor'stritnron6 prescnl Lhenrr-rccuonof the latcral surfacr of tlre fiJrh mcl:turrsal
hc.adrs pcrformed
d) surgca.l pmcedues
I ostcctomr
I rn erseHohnran
3. rnerse \\/ilson r.
){
a
i i e a
4 revcrseAusrn
i rn erseOflset-\'
I|r,
t.i \i
lrn
t J\i
r*
llu
uedrrt
o. aciiucton bsse
D( H
t - l i \ / l fl
r^-l I r I i '-i H Jr
t i L l
oslcolom\' l l I t
1 l t /
l l f I
1(F
7 nfi.h nrcuursel heec
rcacllloD
l l I t

,v ,l u:I
t ) ( i
lli*'
1 l i"1",r-
)r
ll /
, l ' .1 t I Il t
' l , y f l l t
E iornt artlroPla-sn - ' '*+! li I' -i I I \i
\ ) r ll
\
\ l \t

229
 I

IYPLANTS I
inotcauon:
a ) elilnlnate P.ltn
spocer;
b r r c s i x n o r r e n l n n l o l ) o nt q u e s t r o n a b l e ! 9
I
cl correcl dclorltrltr

E-ts-lsr,-
t
a') 1962 - Seeburget
I I uscd duralirumfor hrs hemi I'' lu{TPJrmp)ant
2) functroncdlo cover a necrollc t" nlctaursal )lcacj
I
bl 196-i-Douner

c)
1 ) rotal fball and socket)
l97l-Suucr
tllcsli lacxet
I
I ) doublc barrel stemutdl an errcrnaldason
d ) l 9 ' 7 1 - F e d e ra r r dF e d e r
I ) ulnar )rc3dprosdrcstsusedal l'' ntelrt:lrsalltcad T
2) rnadeof siltcotrc
3 ) rc;rated br )'arp ('7'1) and Freed('79 l
e.) l9?li - Calrrrarr-Nicolle
I ) totai rlnpl:nt made of polvpropvicnc
I
2) hrngcd rn rire mjddic uirh:m arrnlnlo nlctaurrsal:rnciph:ti:uu;
1-l 1982- Suartson
I I total finger lmplant desrgrrmadeof sillcotrc
I
lnto prosdresrs T,
2.\ ciacrotrnteshttrtprceJraled
l
3 ) rcdcsrgncd:rn srrlrcr lcrsron oJ r Iotel fi;lr.-crrmpllnr tn Ncituuer and Cunc; 4,

hr l98r-Sgrrlano
f ) uscd al rlrc PlPl and DlPl for irarnnrcnoedclonntlr

Brql:taterials
t
a ) stainlesssteel
I ) rrlal c3usetcsorPuonofbone
2) stecl nlar corrodc
I
b) Silicone
f ) lou elasrc ntodulus(rclurnsto norma.lform aJtera phr srologrc
2) doesttol hare poterrdal fol conoston
load)
t
3 ) s o f i t t s s u eI e s f x l n s e( f i r ; a r r o b nl e n c : i p c r r l l t r o n ' t
4) 'ta\ c3use
5 ) bnne rcsPonsc
d e t n r u ss r r r o r i t i s( c i u r d o f s i l r c o n el D s r n o \ - r u nct a u s e sc h r o n i ci n f l a n r m a t i o n )
l
Polrrllethrlnrethacn'late
c)
f ) b"onecentenlusedto hold rmplans rn placr
?) erol))ernuctescuon u'hile nrir:rlp nrav causeA\'\
I
d.t Lrtarutulr cohdt- polvctlrllcne

l m p l a n t d e s r c Yi rf u n c u o n
t
a) hemi - )z:of tre-iotnt
1) utdrcariolrrs arthnus oll olle sideof .iotltt
2) S'rlansongre:l loe - c,nca\'eheadtrth a lone stem
roe - l-i degreeD-AsA lo compens3tefor ebnormaUt high
3) \\'eil modlfic:lron t2;.c3r
l
P.{SA: shoner.raPeredsem
t
230
I
 ,t) Suner- u'tth ol u"ithoutlntcinel or er-lern:l ciacronmesh
-5) -Trnnrum -
biocompaubl€:-otantum oxide coalJngreslslscorroslon
o r i r r r p ) a t rsii r c r u lldt u r t i e rt i t l t i s i u i l l po i r c t l t a t t u t t D
L lo t t r
bj toul - tnth sicjesof.totnl
I ) one comfnnenttotai
+ guanson- ccnraj "Ll-'lungc urth opretun-e
dorsallr'.no angulatron

"-ioi
--l-;\

iz-l '- ' lrfi-'-

? \r.//
J \_t_-/

+ Suncl- proximal scln:rngled l-i cic[reedorsal]r'toacconrmodete for rtreurtarsal

declrnauonang)e9 LaPona
- r r e u t r aol r l - i d e g r e ca n r l e u i t l t p l a r r u ua n s l eo n c i r s n ls i d c ) L a r l r e l r c (
+ S l n r l a n os i n r i l a rt o S n a n s o n
2l r \ \ o c o l l r F E n e nt ot t a l s
+ )rocrug- ttt-:rnluDt prorrnralJ\.QrJanuulrp repiitccslilet:rurrsrlcondr lcst.
polverhll c ne d,rsa.lh': t .\O trarsvcrse stabiI :n
' Bro:rcrron & l,rneuc - nrenurrsli conrponcnl= cobeltchlonre-piiaiugeC
conrfnncnl = utanlurn urtlr polvcrhr'lenecolerug: NO rran-sr,crse stabrittr

23t
 T

H o < rR c s r $ n s c
a i mareriais-ort he biochemicalh inen durabie.non-imuttng non-toric. hrpoaliergeruc.non-
t
: ; l r ! u l o ! c n t c . n o n - p \c g e n l c -l n d h e n d i ep h r s i o i o g r cs t t t s r

hcir-S!!A.n:-
I
a t h a l i u r v a l e u ss - i t h s u b i u r a r r o nh a l l u r n c i c i u st s h o u l cnj o t r r u s e r ja s s o i e p r o c e c i u rfe I M u r g i e
grcalet tun l{ degrees)
b.t rerrstonal sruSen
c ) rireunratojd DJD. goul
I
d t ostecxlrolrdrajfracture-tltua-arucularfr.iclttrt'
e ) hatrrntcnoc.clantoe. mlllct toc I
. ( u rs r c a IT e c l ) n r o u c
a ) nt:rnujtn lcngthof nrctii::rsrl and proxrmal phaian.'
b) all rc!urre sonleIcanung of the medulian canal
T
Ci I n s l n u l l nc a l n u l : ul n l e g n l \

k ;rd ro e ra-Iirrs-Anahst
I
a ) check al-rgruttcttl ard ;rositronirl the nrcdullan catral
b) drc rntUelr-n]'mev shou sorrreScf1.lr:llton
I ) r t o r m aul n r i l t h e l " t t t t ' n t i '
brtu,eentnrp):-rnt
and fnltc
I
(pr1tp-|1c111o41
a I n u r r c n a jf a i l u r e
I ) lntnnstc(ntciatarsallrcadrrrcgulariues.srressfractures)
T
2 ) c \ l n n s r c ( e c c en l n c p l : - l c c n r c nrLr u d c o u s l el - p n cl c s e c t r o no r s o f l t t s s u er c l e : s t : a
b) nttcrol,ralLttlel)tabon
of stenrciunnl tnrpl,;tnutlon
I t rnrtjaiabrastcln
---
t
lnterJace) glonrlttctu<eCa:
2) lrc:d abraston bone.iirnpi;rnl
at
mcul jntcrfacclo prolccl impianl lrom Lrcingcrcdcdbr
bonc
r1
l-*)
f R

I I ' l
L r l
c) .rurra-anicularbone clsts
d l llozcntoc
I ) due to prolifemuon of bone seconcj"an' to DID I
e) urtrarncdullan' fibrous il1'perplasra

I
iront enlargedttrcl;lt:irs:li jiutcj or prorrnral phd;rn-rbase
I ) seconcan'loescpllcnc'crosrs
f t r n f e c it o n
I t ,6u1s(4096of inJectlons)rrrdlrn -{-7 d:r's to a mon$ pcsl oP
? conrrnlrrttlon dunng surgcn
i h c n u l o g c n o u ss P r c e d
r c o n u _ c u o us sp r c a df l o m i r e r r r a t o t t t sau. l u r c se. l c
I
2 ) delared& lare t607oof rnfecrtol.-rs; uithrn I llonrh to 2 riars plsl op
+ " d m e l r p s e - c- f l e c t ) b : r c r c n ac n r c rs l t r r n eo J s u l g e n a n d p r o i i f e r a l eu i r c n

j.) ucar:ncnl
t h e e n r r r o n n t e ntls o D u m a l t
+ removal of imP)ant
- S\-nO\,eclOru\
+ bone gnfun-P of clns
I
* f u s t o no f i o r n t t c h u l : r r i c d l v s h o n c n st c ' e t
t prophllacuc annbroucsi sraplr-cpr
.l vanconr\cul
r cUnciamlcrn
I
l'
I
l ()\\'ER EXTRE\1lT)' AhtPUTATIO\S

I G e r r e r aC
l orrcePts
A Drsarucu]arron-. - cionern childrenbrcauserl prescn'estire epipblsealpiate aUourngfull lillb
glo$th
E Anrpuurron lcngth - rn gcncral*rc )ongcr.t}lc bcner both phlsicaUr and mcnulh
C Gatt veicrciuesciecrease nith nroreprorlmai anlpuL3llons
D C-omplicarrons in hurirng ploshcsrsfirrrng rehabillutton anci
are ilre nrlc u'ith drlTrcultres
y'rossibl e add:tIonal arnpuutllons

ll for Antpuuttons
lrrdrG'tllons
A l'numa tcrushrng. mutilatrngt
E lr4alrunant lteoPlasra
C Unconuollabletnfccuon:
D Anenal vasculardlssses lmcirnglo glngrell€
E Selere deformitles{non reconslruculble)

ll I A n r P u t e t t o nS u u s t l c s
A 33,ii, of psuenlshaunp unilaren] rnrpulal)onu.rll l,lve the contralatenlUmb antlrutated
alter
3 r'cars
B 33'7' Sun,llal ratc 5 rc.aJsftosl-op Belo's'knce -Anlputlltton

1\ Louct Errrcmin'Amnurationr
.A H enupeilecromr'( rnabcnancrcs and failed .Abore Knet A;lttputallons l
B Htp Dtsanrcu-latron tmalrgulnoes:rnd f:uled Atxl e irnee .furtpLrt3lrons)
C Above X;ree AnlPuuuon (-ALA;
D X,neeDtsaruculauon
E Beiou'Knee AnrPutationfBLA)
f horimal SvmesAnlPutatton
G Puogoff -AnrPutatton
H ChoPrrt Dtsrnjcularton
I Lis Franc Disamculation
-l I enlinal Srmes AruPuutron
N Rar Rcsecuon
L I ransmenursal Anrpunuon (Tltl-{ t
M Digrral A:nPurauon
N G u i ] l o t j n e( o p e na m p u l a l l o na l a n r i e v c l u h i c h r c c u r r c ss r a n u l e t t c lonr d e l a v c csi u r g r c a l
closure)

lV PnnciPlesof AmPuutton
A , s i r cn t u s u r l h s u n d f r i c r r o nf i o m p r o s t h c s r s , ' s h c cush t c h n : a l c s p ) a n u rs l c n n t o r ei d c a ll o l
ueightbcanng flaPs
B scan shoujd not adirereto l-'one
C ::rojd urureccsssl-\' prcrcedutes lo lJ'llPto\je coslllcllcrlulcom(
D tendonbalancmg
E altpulauon srteshouldbe free fronr cellulius.hntplu:rsjtrs.and eciema
F flap shouldbe under no / minrmal lenslon
C acicquate hemoqa-sts to ar.oida pabulum

\ horrmel Srmes .Arnpunuon

A rou.l foot ampuulDonthat mal tr used rn hclthr p:dents ui$ severefoot u-auma
B nrediajand lateralnralleolt are lesected
C pres€n.aDonof lhe c.aicancai1atpad as a f'r:stcnorr plurtar fl;p to u-sefor u'eigltt karutg
surface
D dog mrs :rrereriscd I secondsu5c of prc'ccdurelo prc\ enl ulccm:on
E hjglr rareof corlpljcauonsn'itjl plosr}euc fiurns ald disrl ulcerauon

23i
\/l hrogofl.AntDuullon
A nrodificatronoi prorrmal Srrnesilrat presenesthe ca.jcaneusfor iengtJiof linrb
B. fusronlxtrryecn calcltcus and tibla
C high rareol conrplrcatrons u'tlb fusion and pronheticfinLng

\ll Chop:rrtDtsanlculatlon
A presen'esa iong pliuuu fiap rf needed
B lugh compircalronrale.c-.fEcrali'\equrnovaruscie{ornrrn'fTAL or achil}esletrolont\
rcconrmended )
C p r o s t h e s r s r e conrmcnded

\;lli Lis Frunc Disrnjculation

-A pt( scn'esr )ong pllnuu fllp if needed
B ntcdrunrconrpirceuonr:.rtc- cs;rcci:rJllceultolrru-<dclonltn' (TAL or achlics lcnolonl\
recontntcnded t
C plosdreslsrecoltlnlcnded
D do ltol lclr e anlcular caruiagcurd plarrerenralruilgul)c\.cn.iorntsurlacesbccau-se utlevell
s r t ed e l r v s i r c l l r n t a n d c a n l c : l dt o p r c s s u i ef v J l r t l l
c a n r i : . : gseu r j : r c ca l l ) c ' r s ) o n

I), Tr:rnmtct;ltarselA;ttPut:lu<;n
A \'lost coltrlttoriiru.redpiorrmal looi anrprutron
B srcraurrsals uansc:ctcd at cjrsrall/3 rn a slrcndt nrr.ltnla u'ith t.lresecottdLr:rrrgthe l<lltgrst
alrd tiie cuts of lhe nrcr:lurs:ls should bc a,ngleddrsral-donalto proxrntal-plant.iu urt-h
merrursal I angleci prolmal-nredjal to drsal-iaterai. and nreteurrsal : angled prorrmal-lateral
to cirqal-mcdia]
C. tttuslitave long Pianul fl:lP
D ankle ftxrr onirosrst.AFOtlnd cuslonr lnoidedshcv:su'ith toc filler ancircrker hnttont are ven
trncfi cral tn rcJrabiltratlon
E ] o r r c o n t p l r c a l r onnr e O A L o r a c h i l l e sl c l l o t o m l a n d p n s s i b l ea n l e n o rt j b i a l r e n d o nl r a n s f e t
to iateralstuntpf<lrtendonbalancutr

-\ Tcnnrnal SrrtlesA-rttpulatton
A 16n16r'a1 of all or Frn oi a toc
B fla;r.. used Jot closule
I fish mouti tnrosllr doneon llallr-rr.r
2 )ong Pl,irnul
j s i d et o s i d e
L n,cquel
s ' n o u r j s } t n r e n lf r o m s r n o r r u m )i f d r s r n i c u l l u n g
C r e p r o \ ec a n i b g e { r e c e r v ei u
I \ T E R I I E T A T A R S A L \ E L 'H O \ 1 A
-tr4 t
a.l; a or ut' s l' eur o nn
' "
:rrxi ;uuiiui idli{ltdlj of L]iel<xr'l
...:.ry,r--:-uira,r
- T i r o n u sG . \ 1 o n m l E l t

fllS l tJn )
I t - ^ f n n \ '

ll{rt.i Duriocner, i- Ongnoi aercnptton o-l'ri.u'a.s*

Itj?6 Jlorton.7-(: EuoJogr'. Cr,mttresnon o.{inrera! ptantar nLn:t'betuz,en /'& -su'-\.lr,orttr.soi
heads: recontntended.rttptcoi exct.sionof f net heod
18E: H,,odle!'. .4f Ftrst ttt exctse thtrd tnterdtE tol nenl
I 897 .Jtnes 6' Tuhbt Etiologr'.' .1 c'ontntuntc,attng br anch it,u' neri ol and iarerai piontor nertp.s tt'o:
corrtprtssed b,tt'the f nteto!arsal htaa ond the grounci
I 94() funs, LO Etiologr'.' 9:condon' tu strctclunE qf 3' d' f tnterdtgttol rrn't's uncicr clecp
ttan.\rt!r.\e tnlentrclolot'.\al lt,t,ottienl:ol.sOf tnterdtB,ttalnen,e iS lar.per
httnu.sc of arlritttnol-til,crs.lrr,n inttral pirtntar ncn)c (:(tn,rnu,u(:attnei'tranch
I9-lE -\'r-tren.li,/ Erjolc.gr'- lrchenttc onfatl Io tiene lesur,
1 951 .\lulticr, JD Etioior-r' li cairic.s-ro{ Ittc rrcn:tvnc orch o_tthc -towJltor rc.tulLs tn
h-trymtobihn'q/ thc ntctotorsnl.s cllovtn!' tht tnterdtgitol ncn'c-s Io brcorttr
t ni tated ortd i n fl anted u'ith .fth t t tu:
I96-a Ku1rcll6' Etioiogr'. i:ntnattnrcnl n(urulnln.r'o{ the tnttrditilai nen,e s!:(\)ndun' to Lruunt.!
TnotnPsvn

!AILTQCEI.ESI=c
' Truir unfrtoul'
' N 4 o slti k e l r c t i o l o g \ ) s a n ( n l r a p n ) c n rt l c u l ( r p : r l i ls\ c c o n d r n t o s t r e t c l r u ragn d i m t a t r o no f t l r c
rnrcrdilrrulncn,eas,l Fr.(\esunder infenor to t.hedecp u:urs,crsernlennebtarsalLganrcnturt)t
re;rtitrve donillcrron at lriTPJ dunng antbulatton

H|ITOPATHOLOG)
T h e t c r m ' n c u l o n r a t s a n u s n o l l ) e rr.t r s n o l a l u n l o t o I n r 3 s so u l l : r o \ \ r n gf i o m a n c n t
',
.\c;ltro.gs ond erittrtc o-[ eltt tiruriurn
'.
TJitckentnp ond h1 oltnt:ot,t,n oi e,idolheliol r ' e . s . s e l st n a n d a r o u n d t h e n e r v r
'.
Thtci*ntnp and./ibrofls ol cpt-,pcrt-. ond encit)neurtun'
''
L)emt'eltn:olton o.l tlen'e./il)tr:

DIFFF.jlENTlALllAQNQSl_s
. -4bnunnol ),lttator,solJ)ttrohulc . .\4(tot,rrl'usl)r,)xirttu: . Freiber!'s in-{orctt,tn
. l;osarlar l.g:htntta . Pirtntar Fot Pad -4rrt'phy . l-)-tyrcrntobile,\4etatarsals
. Cap.sultn.\ . -\'t'unl1.' . 7 rountoDc Rur.rltt:
. Gangltun Ctt . Eoithtlttil C t:r . Frtretgn BtxA
. ,\{TP Jtun I Svn,lrD., . Rizrurnotrnd .\',,riutt . -\'letotnr.sa/.9rc.ssf roc;turt
. Occult Frocturt . Rndtr:'tlofth) . J'rc-])isltxotton Srndnirtte (PDS:
. Torsol Tunnel Strttlrnttte . Sr'rr,l'ial Crrt

r I8!*
AL_U4
cu]{ leal_E_\,
P n:r'n u tioo cha ncttrisr rcr
'>
lemale>>)|oie
. Third to selentt decade
r -\1o.rlccvnnr)n tnlersltzc€ tm'oh'ed ts the 3rd . closelt'folloued b]' 2nd
'.
Ftrsl ond_fiturth tnten'x)& ore ror(
. lr4ulriple interspecetnvohentenl rare <1o/o {-fhonrpron & Delrnd E-ll. ian 1993 t

23:
 presenl n(int nttnllts prior I() alicc'"'lsti
()t1.sxlo-l snntonLs
L)rac-,tai
St'mtxttrtt'
ng t xu t'
j- o l eidtu rnt
g r otvtol
- Aog re.t
squannS and ttgttt ilo( ?t(1'
tttltt anbttialton'

Shorp sohbtttg ratn

dtgzts
Potn rodiattttgto tm'olved
-t

Relte-fot rtst and llln's\agt

Stgn:
. Dilnnl h1'ry'tlttcva
."n"llnC,tcjble
of foreloot
; narns'irh lateralcotllpressloll
', (SPintng of dgtsl
,sulltt'an s srt'n
l. y-, lrct""')" and-tu'ttpronnnl to nptatar'snlheoci'
, PalPhlt'tntLn)Ploldrsalntav
',
),luiier's Clicl

S
t\'EASURE
A-DlUeTI\'r CLlxleAL
) Ruli,ryraPh.t'A-rm't
. To fuO osseousor arthritlc ;nt}lologr
(tfrlJ;
) Ilagna)t' rL'v)nunLt imqing
t)r(o ol d(cr.'o't'i .v.!nai tt-l1(t1\1r\
tt:'_irx:r.ti
. 1jt,.rysrt,ntrn Tllrrrlght"ri Dnt)!(:
of )csron
. Cood lor derenninrng e\1elll
(LSt
: IlbruYtnugraPhY
. Rclr on abilrtl lo lnlerprelel
. UP to 981'usen-sluve
(E\1 G )/ N o't't ct t n du dtt t n ycl t x in' A C I
E l', tt, r,m.t'l4 t up h'
. Nol toutlne d-ragrosttc ptoceoules
. Uscd 1or at-rPical Presenlauon
pltlrologr
. R/O more proumal neural

N'I S
eQNSEBI4 rry E-IBE4 l]VE oi smrPtonlstn l()-l0"zoCaSe:
) Prorides-r:oodicnporan'reltef
7 Gelrer.rlh;nor long-term eflecurettes:

block to intcrdigital -sPatr

Dtr.t.?rrtslicltrcol ancslhctic
Ilide-t1'e sJr* t'ot "
( " Ctnl;t e Jxrd ,
P o<it)t np ond' ur s rapltt ng
Ortitortc:
Phtstcol IheraP\
csis
i o n o p l i o r c s ls - P h o n o P h o r
l\lctrzrarsol i'at
()n (S)
C t )rl 1(( ).q('r()td tnl ecl t

SlBqlqA!-BE-Al-N4Elrr
()flrrs lx'st dcfrniir e trcatntcnt
-/Glo0u,n
;;;i;l; of c2scsin rhe lirerarur(

ci
l-trc-tft-Sl31 3I52Lq3
I Dors€l
I952)
.{ Longnudinal(lr4cKeeler
to irterd:grul nen e
, Prorrdes good erlnsu-re
) Ar oi& seig:lrtbe:nng scat
; ;;;; i c-mrncisronb/n'meurarsal hc:cl'
llgarllent[DTl-t
) Tranrecl decpuarsrerseiltemleraurrsal

236
 B \\;ebs;rce (\4cEh'ennr l9{3 r
^, -lncf
sion through the'i{€bspace exendrnp I -2cm ciorsal}r
, Prorutur c\tl-)sutc ;-In D€ d:Jtrcrut
) -Alio$.SJol carlr $eipht-brc:Lnng
' AvoiC<neight be3nnc sca-r

I Plartuu
Use iarge g.au8esulure
A LongLrtudrnal (Hoadler'1893)
) Appros. 3cnr rncisronbrsect:.ng rnctrtarslllread.
' N e n ' e t s v e n ' s u ; r r f i c i a i l r o t n t i u s a p p r o a c ht J r e r e f o r e .r c e l l e n tr : s u a l z a r r o no f
nen,€
, Less drssectton
' Prescn'cDTTL
; Can ransecl nene nror€prorrni-rl
i ir o re.ridual rieocisSncetherelbre. riecreasng
opr)n untn' lor I rcntolotI to.lorntolron
"re-do '
, Scsl ::pprorchfor l)eu:onrl or slunlp neuroml

P Tran-clersefNissen 1948)
) 2 - l ' c m c u n i l r n c a rr n c r s l o no \ e r r n t e r s f x l c € (.si u. )s lp r o r r n u l t o p i a n u r d r g u l s u l c u s
' Optron ior nruJupleirttersnrccn(-urolr-u;
. Lcss pntcndal for hrlx'nropluc scarlornrationvs. lonsrtudrnal
, lr4ore pnential to drsrup pl:rnnr 1arpai
, lncreasedrisk of cotnptonirsurr;xr;r:ndrcuiarralersrng sulrrlrcial neurovascular

Prtx:cdsrc;:
I Neurectomr
r Ercrsron of t-heinterdi6rtajlren'e and rt.sconcollltalrl t'rranckr
) \4ost conrntonJvperiormedsu;grcitjpro.ccurc-
i Dorsal or plantar approacb
. lcjcnull and ex?oseall rren'ebn:nclrespnor lo reseclron
;' 8()-ti-i9'"Pood resulrs

? EprneuroJrsts
) lnrerdjgLrl lren'e is fiecd form sunoundrnrsofi tlssuestruclurcs.li0rout ercisjonof
l)en e
. DTIL: (a.)rem:xnsrnuct. (b')lsuznscctcdor (c) ls transected:rndrcplued
. Presenes sensaDonto the rnterdigruls;lce
i Addrcssesetiologl of enu-:lprtte nt ncu-ropa*tr
, Rc s u l r -
> f-)elitn.-4- transecttdDTIL. AUyocttntpletereltel'
' Guthrer.G- u-ansected DTIL. 8lo:acrccllcnl l4or'o unpror ed
> Diebrtlder ot.- fttllot. -up DT1L released:92.5oh
exr ellent

POST{PERAT] \/E, COURSE

');
Contpreslve de-tsnF
i Use of a drarn rtravbe coruiderednith ercesslre bleecirns
I 72 nours
lce and elevottrLn-t:or
, Patn nrdrcaLon
, Partial uvipht b+'annpto heel vith crutchestn suracal shu
i Suture reruovaj 2 ue}l.s dorsal incjsion and I u*Is planlar
) Rerurn to regruiatshoe grcaral 2-3 s'eels

231
Ea-Srja!-qC€!]e::T]QN s
'. inastonai scu,
Jl etnuttmu
'2 ll ottnrl (ieitt.u:r:
rtL,
.$ump ,t(ul.,mtl lu'tlrt rl(ur(clt'ln-\
'r jn_lecttor,
Recttrrance (v'tlit ePncurol.tss'
'. Hty*rker otott c it's tx'
Ecienn
', Parcstheso
Disltai c\'ntractuft
. H'nng tnlersf)oLe odcirersea .4neflne.sn
t fiYPcahc'eo Shn siuughtn'-'

ALIEB@
CO2 LASER
I
]Endc.scoplcdecomprcsstonforu]lcrn]Cuurrsalneuonra(EDIN
. Dtscnkd bl Banen & hgnerl JF'45 1994
3 Cn ogcltlc cienen'atton
4 Pelcutatteouselefltcoasulalton

RF-E!]REE-NEE
, Jiotc t-\ Qll)ro-\ittt(ntlY 2002'
-t
Eltttitt?t
- Ii rtin? citagnos:
- l1 rong tnlersPac(
- Ptxtr -rtrTtcal tecltntgu<
- Failitre to dt'ide IIte tt atts'er'se iltitit'ttarsal ltp'zntettt
' Int:ttnPieltrcnut'al
'l dgtal rn'ne too dtstal
- ron:ect cutnnton planta'

Trs-itntcnt
ro fa:l
' Conscn:lllvc- sJmc as on.'elnal-but nlorc iikclv
) c r c a j - t e s e c t i o l lo f n e n e o I s l u n l p
S u : -.\jortn
- ond Relnolds- 6)?a-t prs. itoci.w'vtna,-.ltrryto ()n( hundred rrn.L'nt relte-l

2rE
 N A I ' O I J ) ' O F T I - I EF ] R S T ] \ I A T A R S A L P I ] , A L A N G E A L. I O I N T

Scramoids
a) nvo rn nunrbcr
b) aruculale ln dlc grcloved suiace of d';l
fint lrreuur..,al hqrd
c) cnsa of rhc frm lneurlrsal heaci
scfnrdtes 0re tu,o bones
d ) fibrou-< plannr prad anclron each
sesxriordto irrse o1 ltroxnral phalarr.'
Irelci secureir tn piace b medial
rcsamoirlel. intcncsanroidal lateral
sssl;roidr! llgurrcnL. ud tJre pienu;
fascril
f .t nurscics :rnd ltr:.zutrclrts
of thc ses:rn'roici
cornpicr
\lusclcr (?)
I crterrsor)rallucislontu:
: e\lensorh:rliucrs brerrs
3 aMuqor hallrras
4 ldduoor lr.rlltrqr-s lconrbrnedrn-scruon)
5 (2) 0eror hallucrs brevls rnredial and
lf
larcralhelrds)
fleror hallucrs longu-. - as it uzr.cl-.
th'ouri ilre rtrocvco1:r..-'rnori,
,l Errcnsor Ca;rulurs

Ligamcnts (9)
I nrolal slg:naj ltcnd
I larcra-lsagrlul hc\1d
-' rncdiaj scsanroidal
1. lateral scsrnroldal
-i lnlcr:cslnloidal
o nrolial collateral
? larcrai coliateral
E piirnueria-\cla ( sbp trLqeru rnto lateral scsamoid t
9 lrun-stersettrctlursal itganrent
. (Lhe lrqarttcnt splrts rnto supcnol and rnicnor sbprs tlrrs accolnnrod:rres
dre adciuqor hallucr:
rencjonlo ulscnlon al bose of tire prorrmai piralanr;

2_79
 ]

BLOOD SUPPL)i TO TI{E FJRST R-{) t

I ciorsairsfrcirs anen
l tlilrrsverse plenuu anenal arc
'4 llr$
planur ll)cuursal anen
T
firs ciorsal nlcntars3l anen
) hnrnchcsof the firs dorsal ntcutarsal anen
|"\ nredial dnrston branch of the frm planur nleuursal 3nen
hrcr-al dirisron branch of the first pLlntar nlcutursd
sncn
t
- planU-r3nen Jontltng cruclalearu-qolllosl!

I
a )r.ellucal brapCh nredial
cnrclaleanusonl()Sls
I t lncdial branch of r}re frrs planur nlcraursal anen
l) llre ral branch of tbe firs planuu tlrculurrstlanen
3) h.ellrrcalbrancb froln nledial planul anen
J) frrsl piirnuu nrcurr:rrsl ancn
l() ciesccndrngporuon of the firs dorsal nretararsrlanen
I
ll coltrtrtonplanur hallucaluncn
ll rlledtal and lateralhallucal aneDes$ith tr.;nsversc
I l.. u:rrts cr\Catu'qonloticbrunch
'|
branch
anasiol.i.lotic
T
J coll:rtcnil :lnenesof t}resecondtoc

l
7.t

t::\

- l.''
,/
r:
a
)( i
il-
t
i, ( l- t

!r
I
j--.....
', \i l . t/t :
\r Yr.l --'':-;
=\\-XJ--'<'1
t
l

I i. I
{
a
t )

t
t
l
I
t
240
T
l
B L h . ] O NS U R G E R \
RADIQLCIG)' oF TlrE FIRSTRA)
c-l-e
ir4 et.'rta :'su5-A dij u-cns Att
at nturs,,td on a DP ueu
b) lormcd bn a lrtte PcrPendrcuja:
to dte brssuoll of dle less€I
tars:-. alld a ilne rcPrcscnurtg
tJtc i sscr llictaLlrsr(
C) dle lL'ss3rlllel,U{rSUSlS reptes€llled
kn the l'rrstsron of the ciorsal
lotrsltudtnei :r-rrsof t-hc shefi of
tjic sc.L:orldtllculurrsal
d) tirc nornral nret:ltarsx addrtcnr-<
angic ts 1:
adducted
6i3-. tlre Jtxri lrrorrles trlore
a grcatet
dls anele 1I)crqlses and
cir:rncc crsts lor atducus dcfornun
al ti''e firsi MTP,tcntlt

P1ott tsIon D-ts:tncr

lr4ct:rr:r15:iL
a) ttiutsrtrej oll 3 DP rrerr
bt rupru'-cnt-t dre dlsrancr bctu'een l\\'o ilrcs
and cicnrolrstntes Ote lcngti hctu'een
ilre fim :rrtd scotrd )llenurse]s
ts uscd to
c il Jrlslll\ c tllilittlrctcr ci:sance
)
rndrcttc tjial dre fir$ rrlcuutrsal ts
lotteer thatt Llre secolrcillleuursal
used to
dr r,cirr'ttt.'cmilltltlcter dlsance is
a
tndrgtte ilrat the llrs rrleraursal
ts slioner tltal tlle strotld ttteuursal
proruslon
e.ttronlraj range of tiie ttletatarsai
dlsurl)cc ls +/- I lrtm
ft rdeaUr. rlre lelrgdr of dre frrs rlteuursal
t-htrd
slrould hc atxrrrt rhc )engrh of the
nlcull3rsal

N4rylF3lSPljrDlSsq!
u) ,t,*.uro dresPlrrtxn\€n ilrefirs n
t\ r)
3n6js(aolld n tct:ttarsais
b) lrrgrsuredJrom tlre mo$ Isleralaspecl
of t\..i \ f
dre firs ltlereursal hrse to dre rnedial
, \\ . i\
cone\ of rlle seconcinletaursal ll
c ) lre3-surBnlcnlnlrr.slr'k m:de perallel
to the \ \iV\
btsauol gf il1g secolrdtlleurarsal
d) 2 ntm or grqjlel rs sigrrificrnt
\ -tu
( [
e) rmponrnt m g\aluaune soft us-sue \-/"
deionrrurgforcesat ilte ttler:rarsai-
arnet{orm-iolnt

'\A1
Mst!Utts.d,DdornAd!den0L
, , ,l,gie ftrrjlroj o' llre blsectlortof tll'
pro\tmal nretaurrsalitse and thi
sirafi of dre firs nrelrurs:il
b) lpursures a1l\ c)ssc'ot1.( delonlttlr of utt
lnetatarsalshai rclatrveto tlte irlsr
c) normal is 6 or ]ess
d.)grcatertllalr 8 itrdtcatesa
snlclural deformtn uilJttn tirt
nrculurrsd sllSi

lrl er:r1r51!.rc rrnSif9]]ll 4!glc

r) dus a-rrglers Jonrledtn dle prorrlnal
firs ltrcutt:rrsalbilse facet and t}t
ntci;al culleifonl CrsnlenlculerJ:rccl
b) ttclrrttalis 2-i or les:
cl elurlcr tiran 2-i implrc: a sntctuntl
dcJomttn

)-'l1I lg-'l Ahl-g qu-<)n rq'rlr1 )::r1.ce?! A rt qk l )

a) Dtslsuredotl ? DP vrerr t t
b.t rcprescnt-<
brsctrons
rirc :rnqlenr"ede
of rhe disal Phdem
bl thc
a'rrd
,s'
n t1

lltc'i.rtscJrott of die prorrrnal phr)arr t t . '

clnornla.ls 0-lo
d ) alt lrcn::-u'€ rn this 3ngle rcprLaLlll(
}1,
.r+J

eitlrct a cnlpertiul fnuirg of tlic

cirs.el Phalanr or a lrdrLsvers(
i )
dsri:ltron of rhe distd Phalanr on I

l {
die prorrnuJ Plularri
el ni:rl alsrr tncrcase u'hen the mollon al
tire firs N4TP.iornr rs limrted
{re-lreljrrr htnitu-<ol rigidus)

H.lllur,4l9"ausrurels
a r on a DP vren. it is dreangleresrrlunc
lrom the brsstron of $e dond
loltgrrudird arrs oI dreprorrltrai
phalanr and the firsl metatal.-;rl
b) normel rs l0-l-i
c) an abrlornrallr hrgh a:tgletndrcatesa
p.-rsittonaldeformln al t}lc frrsr
]rfl?.iornt
d) rlus angle incr*ses in all a-sesof
FLA\; dc{ornritres

1 4')
PrSfUUl-- orlar Set-Aneie
! ) ttrftlroJor a itne ord\\tt pcrl^-ttoicul!'
ro cfiecuve anjcular c.rntlagc
of the hqld of tire firs nteut:irssl
trrrdlr rte represerruJlp iotrgltrrdrnaj
brsectron of *re firs ntetatarsal
b) rf dre anqle nlst.sutedis greaterdun
7.5 . ad:puve c)nttges luvt
ralcrr placc at dre frrs ntetatarsal
hcad rlhich indrcetesa sruoural
aCjDtauonof tlte arucularcanilagc
c ) ilus lndrqllc'sa sruoural &Jornltr
;rrrdlrol a ;nsiuonaj onc

p1 1 a!,An rcrllCLSC!-ALSIS
r ) on a DP ueu. it rs ionnedbr a lrlte
ciraur 1r.-r;xrtdrcrtlarlo lhe cJTccuvc
irninrlal crnilage of tle r^tlstof tJrc
prorrrtral phalarlr
brrcprcsenu snrqural adaptattonof the
irisc of prorrrnal phalaruion the shah
c) :rl'urontrallrteral epiplrlsealclosureat
the hrsc of the prolnral Phalanr-
l'hich cru-<csnrore gronilt nrcdiallr
u-itlra resrlurte Lxnrrttgof tlie slr^rft
nul alter tlus angie

aqe-ealJornt-f o-st-uo!
I us I 4et9I :r1rcplr"eJ
a) tlre -iorlrt p:rsinon olt a DP vieu ts a c-olt)rxttisotr of lures represenu)r dre c-llctuvemjcular caru}ageof tlre firs
Irrc',;larsaiirsrd and a lrne represcnung lhe eflecttvc:rntcularcrnilagc at dte Lxtseof tire prorrmal phalanr
colt-grucnl.iolnl
a ioutt ts s-erdto be conEruenlulten
rirc tu'o anrculal surlacesareu'hoier
rnrcul:u lnd t]ile.lorntsrlce rs cgual n
cicvrated -iornt
a -iointr-.sjd to be dniatcd uien
tlie arucular
dre lr-rrcsrcprc's€rtul)p
surfaccsrnrelr€t rxrtsideof the iornt
TTFS f'-
---- / i

' \ ll
\

sublu.rsl_rornt
a -iorntrs s:rd to tr srblured u'hcn
=v/
/^\-
the bnes rcpres€nungthc an:cuiar \ / '
surfaceslnter:€cl insidetite iornt t
t
l
\

b) a congruenlfirs N{TP.lorntnitJterrepresns a lrormal firs lr{TP-iornror a snrqural adaFauon of l}re firs nrentarsal
llrrenllr. cle3unglullur aMuctu<defontttn
cra cjerraredor a subluredjoint cccurnngal lhe first lr{TP_iolnl rndrqles a pnsrtronaldeformrn

/ - - - 1
 H9!-d(strn onDPuen')
SLlfx-orufftry-Ucurur$l
a) Round
I rourrciiLrs lttctlttltr'€1lr-irocruille:
a lugfi degreeof lrt's'3bilrtral l l
dre firs MTP tornl iI ;
2 t h e h a l l u x l s P r o n et o d n l t l
latcral]'t on a convc\ sunac€ / \
b) Squre firs llteuursrl lread l i

) . prorides more srble.iolrrl l1 lr

con1tgu;-aI I on'r'cr.<u-t I rottltd i \
f:rg trreuursal hcad
l l
c) Sclrrare rr'ith a ricigc \\. ,
I
I n:prescntssgu:lrenlcututrselirstd \ t

uidr a:r oblique or ccrru'alridgt ; l

I seble conf:gunrtron:hetP
prcvcnl latcralderrltrrlnof
dre hallui
-. a conr;-rnsrton' haI Irr-rrnterphalaltgeut
nuv bc ."ecnuidt t'itts

Tihral ScsrrltoidPosttrort
a ) rtiqtsuredfrorn I -7 relsttvelo Uic
btscctronof tirefirs
longrlucirnal
nrcnlarsal
b) rrtsrsuredfror:r rrledralto lateral-t.lte
:
nornralribial s-surroicip''i1'6n 1'
p'ritron is J
c)'rlltcn tlre tibiai sc---rlnoid
tirc sesrtrtordls o\'errloll)gL)ecnst'
of tJrefirs ntsl'1;1rstl crusrngDJD
l F r:
i E l s
dt rhc ubial scsrnloid could dislo;ltc;Llsi l
dre cnsu uitllout erolitlp tl- dits i*f",
rs tr-st n'aluated on a sesrntotd
arid rrcrr

N1ctl:r rcrA.Pn rn u5 {glDfl ul Algl-c

r) lonrred bn'l-he bi-scLronsof the firs
lurrdsecotldnleuursals lottgrtudilralh
br rcrrrcscnua dsrratronof Uiefim
ntcurl:trsalin a ulnsvcrse pllne nrediallr
=
c ) roillusfoot npe. Ilr'1angle 8-12
fcnt trTre.L\4 snclc = 8-lfr
d, :rdorrcrcd
c) tlre Drl urgle could hc tncrq.rs:d tn a
,nrt..eruurllrhrl.$ed or
ttteurutrsai a
prcnrtlure closure of dre nrelial
cprphvss ssondlr1t' to trJunlz
ft ur pcsoperauve filnrs- rf t-)iefoot
is held zuprnatcdsaoncian'to guardmg: fajse posiuve den::tse rn Ilr'1:rneie
s'il1 be noted
e) dirs aneje should bt a-'sss.riol rleiejtt-b€rulg \le\\'s
h r os lnlerntel?larscurTlfound Lcnr,en l]-rebasesof *re firs and sooncl
ntcuErs:Lc coirld conribule lO en llrcrejls€in the t\J angle md to a hr'llur
valgrusdeforuln

lc4
 i1arion -qlPrqepdu_ti
D-ercryr
- posr{p goai to get I}r4 ang}e to tr
I i1llS.!.EI!dS11I1-lS
F. L\4 angics up to )tr usualil respondto heacjproce<Jurs:
E Ilrl anglesabove16'18 r€guueLus procedure'
ll rrtcrs-<edP.ASA
A Reverdln
E Pstbodr
C brPlatur Au-qrtr
D offset\; 11j1i1 nrrvel
III FLA\/ rtith nrcle!t-55ldfuoq'
i. j-LA\r deJorlnrll is liccerrrulledur prekncr o1rncut'.lirsu-<
idin:tus. ltorrevet.the IJr4altg:Je
ntav apprr
Normai or sbgLlrtjrincresed
E considerdrsu-'tncc ulictt choosuteprrrcdurc
belu'en fim end secondlttcl:tt:trs1lhtltci-c
n aqldruoll--g'ilrsjSUt
A. radrogr':rPirrc cltlrnces
L cljlrrcalclent lle-r.lll,PeoJttrouolLfxllrt crepllrr)
\ cortdittorlof rlre i'r.rltc
l. pnsctlce oi o'slc dcgellcratron
E cresslvc sclcrost'
c rltarkedos,e-)1>crctsts
\;l lnd-}!441,91-lenlJll&l!lgrer!
A agc
E antbulrton setu'
C nrcdrc:lls;ttrts
D comPlrlna
\,I lqqlg
.L' irr;':rnrobiitn
E cln 3lr-r'

'RE\4EN4BER ciorrottrqrt the r-rars'

( e!-doLb-aj,a11lC1r-rc
SoI T r-...Ue C on eci ]on a4plUl-e-l Sfdurc!

I S i h ' e r( l 9 l 3 )
A, r(i-dtlott oonorllcdielenllnenc€of frm nlcu:urrsalilcld
E ,"t"ral o;xulotoltn attdlrredialcapsulorraplrr

ll N 4 c B n &( 1 9 2 3 )
,i. res-uotl dorsollollal ellllllellceof frrs nreunrsal hc:d
E iateralar;rulplqrnl uit) retnovalof fibular s:emoid
C rrensferdre coniornedrcndonof adducrorhallucrsand l::renl l,utd of FFIE to clorsobteralasp* of tlre frm
rtreutrarsalhcad

n Hxs
.3. rc-sduon dorsonledralellllJlenc€of firs nremursal ltcad
E lateralca;-nrlotomr
C rr.r:rsfera6ucror lr.rllucrsfroru planur to nred:alto tJrefirs \1PJ (ahluctor telrdonsuturedrnto hole in bast
of proxlul plralaru:act.ca-(Lslarttentto nrettsdienefrsule rrttdialh')

1A(.
L - _
n' colrrr\tnenl nroccdttrc:
adriuclortrarder
lari ous clPsulorftrDiue'
'l
r crsls tr.tnsvcn€plattecorr€ltotl
fronuelpl:-rlre
\\;asiurtgtottlllollulllenl
elirPucl)
"T"
i siu;rd
"L"'s)uPC
:
"L'
t) rnr'cned
a EHL tcndon )crrcdtenutg
n EHB tettototttr

Phal ang ea] O st9o1on1'

I P-ro!mal.-1hr'
A, cornrl-< for DASA
B ()sl$lolll\ ;rrforrlred -i-10 lltnt drsal to MP-l
C J-nmllelto srrdaceof tire hrse of tire prortnral phaiatr',
prorinrai ()srL.t)ronrv
D C)sul os(rlorll ;rr;rnd-rcul:i-rto )orrglrrs of thc sliaJt

Il 4s. -1\u,
A corrrrls Jor hal I ur abductus t nt crplt:tia-ltleus
E osleolon)\' J-r:rf0rrrledal dlsal elrd o1 prortlnej Dlreialrr
scrc\\'. sulure. ntttttofilalllcnt urre)
C ftratr<tnof cjthel ()sleolom)'r':rnestte-lLr<trirrbleptn. il-urrc.

eq2i 1al! sl qQ!q!l-le.(

$rsttll!l!-t
rcr*Ttron nrcdial cllltnencc- lateml rclsrst-
llte Sntl-'
E ()sldrloat\ ;rrlorrno3 ut dte crrrter of rticururrsrl hgld uitll 60 degrtl atlsle bftr\'eett
ut'corr€'ona1. normahzes Ilr4 angle
brcnrrrtrorual. normalv-es Ilr4 angle end PASA
or donil]cr
a!-. ruid. - utjhzt:d ro lelgnjreD-sltonetl pi:i]rurfter
fursrdm.!881i
A pnrrnrilv u-qed tn coniunctron'nitrotJrcrproccdurcs
E Lrr rts:]l - olllr conds lullur aMuaus (PASA)
c os:]colon\
bnnc
l ;crfornled rn nre',-aPhvsal
: flrscutis]cluprorlnralardparillellol]lcanlcu]alsrrfacr
tu'edr:esireF:duith hrse med:all
scrgrndcur rs p:rpcndcuiar ro long als oi nrcurt:rrsaisha.th
:
{ latcralconer tnuo
n Bqsdlnagl=1-|fl7)
n.rodrllcetron: injrjal cut is ma& pnrallei ro *re ueightl^srrrn-e strface rrLtnn t,tt" lo c\]l -lust prosmal to t]tc
animi:l surl.llc of the firs mennrs:l hcad
E aloids plarw sr:sa:lrloidai of dle nrenurrs:l ]teaci
€:rcroles
(- rr oid. sonng the sesanroid JpFlnlrl!
D srnre indrcltlons as for t}reRelercirn
n R e re r d i n l - e i f i ( ) 9 i 7 \
}ateraitr:tn-siatton of tite crpiuJ frag:rtent
n.,acrt".,ronof Rn,erdrn{rtxn: l;rreralconer ls cul allo\\ing
B cotrr=ls for P.ASA:nd I)'4 angit

/+o
\ Be.sdraTaddll-9]lt
.!. qlniul
tncxjifimrjor::prnrrrnal osteotoilTrs eillrer a.t-llledciors'tliici:i td n)artu-r-pror-i::rd-(plarulifle.res
yaglnenrr or dorsal-pror;malto p);rntardrsaltdorsiflerescaprtallraqtnent;
l'- drsral osleoronrl is st:I plnl)ei to t-he an;culat surJ:rq and prorrmal oseolonrl par.rllel to tlrc
u ergltttearur g surfac.

\ rr k /I1 et :rta rs.rI Ostt'rtlrtntie'

I Pc;rhod,
.L. srnre prrccdurc :x Reverdrnc\ccpl thet the oscolornl rs Frlormed al lhe anrtonricaineck
E divdranuges over Reverdtn-
I frnrer hcaiing arqaof i-nnc
: requlrgs s€ure fir.rtron or llon-u'eiehtbc;rrulesullLl(

lr qRATQ-Ilnith. l97li
.L. drsn} oscoronrr-;rr;rndiculer to t}c long:rrts of tltc firsl nrelttlnul. lhroughand Lirroueh
E ltrorrnral oseolont\'- ang.ledprorrnral-lrredialto drnal-lateraitto product PAS.Acorrecuon)
( cjorsrficresaprral lragrrrentro piace tire :tnrcuiar Grnil:r!'crn a nlore {unoional ;-nniron. alrd lhu-.
el the i)rs N4.PJ
dorsjflc:'-ron
;rllcnpl.(lo rncrql-sa
D drs.adtatuges
I frnr heahn-Ptnne
- hlghlr unsurblc
-- leqlt)resssure fi-r:rtlonor tton-u.eiehtir:arurps'rtus
J lrcltnrcallvdrfficulr

IL V Aio_ele1'
Cr{l.*^r
A. lp:r oJoseololl)\ al nictlpln *-:ldiapln'seal.luJ)cliorl(\'cj'susctttter oJ nrei:ursal he.eduiilr Auclin t
E angie of urne-tis iessrlian 6() cicerc'es
C lolrter oscxrtontlalloss for gruter bone-to-bnnecot)ucl
D lcrrgdi of dorsalullg deterltllllesalliotltll oJ sruvel possibic-
F_ :rdr.:tnta-u6
I qrn colT€l for Ilr4 a-ngleand l-r^rlluraMuctu-q
I gcrd Lute-totnne collucl
: caseof frratron (te-Prn:scrcu t
-.1 trrucnl qm be ueightbctrutg

l\ Lalu!
A e;rr ol'oslcolon)\'tn canler of circle eround ntculters-il iru.ri a. rut}t Ausult prcrcciure tnrcr:.rphlscal
(,Sla1.)lOlll\-)

E iong oorrelurng ajious lor screu'l:'rauon

C unebleto srrvel eprteJ fraerrrenllo corrcfl PASA

\ s ,
.!, l\\'o \\?\5 to;crform oseolom\
I dtsralcul dorsd and prorlrlral cut plarlra:
I (ar,oidspnssibijrnof scorLrrgscstmoidapFlr.llus. ,rrsterto firate t
: disal crr plannr and proxmal cut dorsal
E sutular advanugesand usesto C)flset\'
".Z"
C rrougfref'ecr,dorsrl sgntent of the rconical rnne ) u:rnt*.to sinl ooun rnto the planrar ssntent s'hen
sarc\\T3re o€hleneddo\\Tl

-j
1.1
4"1 i
\4 Ludlotr( 1918 t
r, to pJlrntar.irsui.
obiroproslc{lonl\oriellccjoorsaj-proutln} esutg.lus prorrrtuJlo lttertursall)eac
E un$abte osleolotn\ conllgurallol
C gan srrvel for P.ASA colTectlon

\4] N 4 a u( 1 9 2 6 t
A oblrquc osleolonr\ onenred dorsal.Crstalto pianuu-prorrnral cNung-lus prorrn.nj to nrcu:urrsai<uneifomt
.ioiltt toseotolll\ e\acil\' opJloslleto Ludioflt
E unq:tbieoseol0lll\ conigunuon
C adlanugcs
I bnth Ludlofl alrd Nlau are lu$ilr'r'ersrtjle osir:olorltte:
I rire crpiral lnrgrrrcnrsrn hr elevatedcicpre:rcd len-ctircncri.shoncned addrroedor alrjuqed
_- g,rd decreeof frrlre con'Jcrrs nta;nl:-rured rcL:Dtrdlcsso1apiral fn:cnrcnl drspilccnrcnt
j ilre l\43u ()sleolorlr\ $'ould apixzJ ursler lo frrate tcs;r-ciall\ rf usI)P scre\\'s)artd )rat'e sorrrerr.hat
br:rrels:rbiirn aslns dre lorcesol u,etlrhtLrl.rnna\,ersltsthe Lrrdlofi
D disrdutturgcs
J dlapllvs'al ()seolollues- fnor lrealurpllltt
i proslna.l]ocllronof osrtx)lomt'<jeltt:tnds fix:ttronancj,olnon-u'eiehlhcjrntre
s:rtus
-' requtrcsstgntfi,:ml dtssgtron atrrut tlrc frrs rur

\illl !-oilaaqn1l9-2!t
/. rr.r;e;,ordaj()sleoronr\'(rrrdr hrse oncnted nrcdrllh ) ttltcic al drc lelel of lite trrcteurrsrineck drroudr and
rluougil ()seololll\
B adr':rnurgc:
I apiul Jnsrrrcnrrolslei mediall'r'locorrrl for hel)ur ltl-riuclu.
I cepruelfrasnicnr could alsobr raxlated llterallr' (1\4 :ligle coneuort) arrd,cxdorsrlh or pllrrtarlr
-. cortldd:colr;Drcsc
shoncntnt of the ftrs nret:rt:tr-"sl the \1P.1:rndslirhtlr nlcrursenlot)ori
C drsadvanugcs
) srgrrifrc.antsltonetultp of frrs rnetatars'el
I un-<t.lbleossrtclnl\-.nxJulresfirauon anciltttn-u'c1r:hthr:rnllg s:rtus
D origrnal prcrcdurep:rfonncd out-side qrpsr,rleand mcrlial cnttJ)cnce\\?s nol rcsslel

L\ ] r 4 r r c h e lrll 9 5 '
A. oblrqueosl(rlont\ slril:u to JJoltmennexccpturlh lateraiconjsil strul lltti.)c1
Il ongtnah'fired urdl J{) c}trotttrc catgut
C and cirsadlanla^pes
sinrii;trtndrqttton^c as Hohltralln
D indtcltrors: lonc frrs Illclillstssl

-\ \\;i json
.A obl.rgue()slcr)lollt\orrcnredd-rsual-medial to prortnral-lrtcral (throuehand tJrrou!:lr
t
E caprraliralrrrenl rs shrfiol prorrruellr a:td llitera-llr
along tJreos(lrlorlt\
C crpim) insttent c:rnalso Lr u-anslated dorsllr or pianurrlr
D di-s-rd,uuge:
) Pru hcilrng Lr.-rtle
I urstable:rcrprressecurefrrnnon and,ol non-uelghtir:rnnQsullus
I pndues sisnrficantshonerung

248
BasalOseotomies

oF TrE BASEOSEOf! d
PRI.TCPLES

lunee a;ris concEd

. hinge hasan aus and arms
. moDon about the h-rngeoccuts perpendicuJarto tlre axis of Orehrnge: keep hrnge perpendiodar ro the
u'eigfrtbeanngsrrhce so t}tedisal seerlent remarnsparallelro tlre groundu'hen osteoromvis closed

hinge oiis musl be perpendrcuiar to t-be ground rn the saglnal plane- to avoid iarrogenicalh- induced
nteularsal ele\?uoll
&rrsomediaj conical hinee planurlleres the dtsal segmenrupon closure
olantar nredial conical hhee (runs dorsontediaj to plarnr lareral) dorsilleres the disal s€gnrenl upon
closure

conlDIelUOn-(
. first t4'elazrus
. lessermennrsalgra
. hallu:i t'aru-c

PR_OC.EDIiB.ES

I Transverseclosinp ba-ses'edee 0iison. l9Ol)

A o$eolonl' origina.[' descnbedas berng at a point 1us drsul to t]re insenion of the long peroneal rendon
B. baseiareral uith medial conical apoi fuua
C. adrznuges
t. longer lever arm allons for correctionofsignifcant IM angJedeviadons
2. good vas-'ular bone
relativeh'linle dissecrjonrequired
D disadrz-nuges
1. FoNimaJlocarjon of oseolorm' 0onger ler,er ar:n) demandsf,xation and non-u,eighDearingsurrus
2. grearerpotential for dim:rbing blmd srpp\'about the firs metaursal
3 teguircsParientcomPlirnce

249
tr. -_ oP=bgEctosln+seu€dseOur a l9]9)
A oneruul\ obbqueseoon oJthEllleullarsal" perfontieOar rlieiuncriori of the rnid'lie
.*.ma * t ldor:Ule
and proxmal thud'
B. modi6cauon:
ob[ queosteolorll\- -media] to drsal -lateml
fr ont proxi'rnal
I
2 proximal conicalapexis malnlalned
3 fixanon u'lt-boneor nvo scre$T
C. disadt'anuges
I re,qtxtesmoredissecrjontlun Loison oseolonT
D ad\"nug6
I easierlo fixate
2 morebone'lo+oneconuo

m Openinebaseutdee (Trethouan 192I)

A tu.,* oo-a*.-ao6 uledial rc lareralacrossdre baseof the fim nleursal keepurgtire lateral conical
htnge muo
oseolomv slle
B fashioned the resecrednredial enrinenceinto a $'edge and forced it rnto the
good for nraintaining or futcreasinglengrjr of firs rar
C
D. musl be cogrrizanrofjamming at lhe MPJ
the autografi to resorb
E. t}le high loel of load al the proximal asfsr of the f.rs nreuursa] often causes

N Oseotorm' (Xozenberg)
--oo*,or^'onenled
in transverseplane l*it} apex proxirnal

:C rescenrjc (lileinsock) jotnt

""-a"11,crearcd aproximateh' 1.5 cm disal to the fim meuursal{uneiform
oseotonn'faces drsalJr
B. *,lren loolo'g at the meutarsal frorn dorsal to pianrar. tlre cnncaveporuon of tlte
is aturned
C r1e disal segmenrof r}le firs meurarsal is rotated until the desited correfiion
the dorsal segmenl can also be dorsiilexed or planarflexed as necessat-r
D
E. resuls in less slrortening than u'it} CBWO
F flxation and irnmobilizqnon is required
G. crrplcadons
t. ele\atus
') .rifhcuh to f,rare
J. irnccurate red'rcuon of the IM angle
\rl Epiplrrsiodesis
A fuse lateral side of epiphlsis during gpunh 1'ears
B. (allous groulh on the medial si& to redrce the IM angle)

Combi n ation n rrxedu res

I Insescino (19a8)
double oseolotm'of fim nreutanal
l for shon f,rs me'.ararsal:Rarerdin + Tre*rouan
a for long first meurarsal: Rel'erdin + Ilison
B. adrznuges
1
I colTectsfor high IM angle and do'iared PASA
botl oseotornresare placed in good meuphlseal bone

n. :
capsule rcndon balanceProcedlte (Silr'er or McBride)
B closulg abd:cton' baseu'edge oseolom\
C. proximal Akin oseotom)'

250
Arrhrodcscs
L
A head of the firs meuursai is fashronedinto a peg
B. bole rs fasluoned rnto tbe baseof tbe proximal pbaianr
C the bones are unpaoed and a compresson screu is dnven fiom the planur aspect of the baseof the proxma)
phalar.^^_into the shafi of dre firs meuursal
D. McKeever advised 15-20 of MPI exlensions'ith 15 of hallux abducnrsin men and 15-25 of MPJ exenston
u'ith 25 of hallux abd:cnls m uonlen
E. Indicauons
l. grossll' arthriric joint in a pcrson q'hom vou deem too voung lo have a Keller anhroplastr
2 salrage Procedure afier ursucces$rl Keller
3 so'ere RA q'ith lateral do'iation of the toes
F. Adtanages
l. u'eig.lrt-bearingfuncdon of the preat loe is nurnuu'led
2. lessenthe rcndeno'to dn'elop lessermeuursalgra

U l-apidts (1934)
A dertudedcartilageotrfi.rsmeuursal{ulteifontl.ioutt
B. deconicared lareral a-speq of the base of the fim meutarsal and the adjacent surface of the second
meuursaj base
I packed bone clups ohairred frorn the res€cted ltredial enrilrertceir dre sFsce benveen tlre frrs ald
second melararsai bases
C. lndicanons
l. pain on ntotion of fls nreutarsal{uneifonn-iornl
2. htpermobilil'of the firs maaursal<uneiform jornt
3. DJD of the fim meurarsal-cuneiform jornt
4 ven'long fim rat
5 ercessh'efirs meraursal elnztion or planurllerion
6. oicessirc anguladon or g.3Fplngal the fitsl meEursal{uneiforrn jornt
D. Disadtanuges
I produces mad(ed shonerung of the firs ra1'
2 comparativell' long PosoP Perid
3 increasedpotential for dimuburg tlte blmd supll about tlte f,m nteuursal
4 rcchnicalJl'difficult

Arrhropla^sn' of the Frrs I\{PJ

I Keller
A technique
l. resefiion of one-fourtlr lo one-third of base of the proxmal phalani- lrtr crrl perpendicularto long axis
of the sh,afi
2 r€s€ction of medial eminenceof firs meraursal head
3 medial caPsulorraPhl'
B elimirutes rs'erse tnrckling forces across the fi'rs MPJ
C mainl)'resen'edforel&rh'sedenun'poprJanon
D. modificaoons
1. EHL lengr.lreningto help prevenl rerafilon of toe >sesanroidremoral
2. pin firztion to ma:nuir lengrh
3 capsuleir:rerposidonal MPJ
l. reanachmenl of short flexor tendon to mrmp of phalaru; to increase $abiln' of-ioint function
E comflicarions
l. cock-uPh:llPl
2. lacli of Puchase Po*er
-i. shoneningof hajiut
4 lessermeuursaigra

251
 I]. -- Stone
-
A- obfque ohecroun,oienteddorralio planur leaung plaxtarmnd-vleandsesanroid
appatantsintact
B reseclionof medial of
eminence firs meuursd head

m M!rye
A excision of -i mnt of meurarsal head includrng the aniolar srrface
B inrerpose capsuJeand hrrsal Dssueberween &e meuursal and baseof proximd phajarui

l\lisccllancrxrs
I Openire n'edge oseotonn' of ntediaj cuneilornt
A descnbed for meutarsx adducrus bv Forvler
B. bone graft m4'be allogeruc or aulogeruc
C conlPbcauort.(
I o\fer@trecDon
2. nonuruon
3. fracn-ueof internrediatecuneilornt

lmplants
. suupl)' intended to nrarntain spaceberween boln' surfaces
. GUlnOlCorrec|for osseousdeformin'
. an)'oss€ous&formiq'mu-st first be correctedprior ro implant use
. osteolomiesmusl be precrselo Dre\/enteccentrjcloading of the implant
. good bone sock is requued to recEive sem of implant
. foreiglr bod_r'reacuoneuher due to pnmal' rejection or to implant br€kdoun u'itlr deridc qnorins rs
Possble
(lemporan'nature of tie implant)
. Ft3denrsmus be made auare of short lifespan

I Hemi (Suanson l97l) [Dou'CornineWrigbtl

A ongirullv dtsig:led lo supplemetltlhe Keller buniotlectom
B medical grade.high perlormance silicone elasomer
C. fla Uase- provides no correfiion for PASA
D available in tiuniunr as well

I Hemi-eneled OVeil modificadon) tDou'Cornins Wriehtl

A base rs angJed- lrat'ing rncreased&p} ott larcral side
B desigrredro aniorlate s'jtr an adaptedmeuulrsal head (deviatedPASA)

trl Total Implant - Srran-son Dessr [Dou'Comine Wrie]tj

A double semmed inPlant
B resecredsurfacesofbase of proximal phalanri and head of firs memarsal musl be cut to be llush u'ilh
implant surbcs - eccentric load drsm'butjon qill lparl to earlv implant ftilurt
C. not€
I agztn- tle rarious oss€ousangulat deformidesusl be correctedpnor to implant piacemsnl
2. roral implants canDol be used in t}e presenceof q'sdc deformarion of the fi.m meuursal head
3. toul jornt intplans arailable u"it} tiuniunr eronunets nhich provide prolefiive urterfacebetw'eenbone
and imPlant

n/. Toral Imnlant - hPona Dessr lSunerl

A prox-ural $em is anged 15 in sagnal plate to accounl for fi.m llteutarsal decluuuon
B. drsul sem is ang:ledl0 lareratr'rc proride for ph1'siologicalhallux abducnr-<
C. hinge allous for 60 of motion

252
 A proxfulul stentalsoarlgled 15 irt tlte saginalpiane
B distalsem is no angledtneuual)
C. hingeallousfor85ofmooon
D. allousfor bevelledplulangealbaseresection in anentptlo presen€plantaruuenrotl(

fno Comronen foU ton

I KoenieToul Toe fBiomal

A noncemenled s_\sem:tre meurarsalcomponenlhasa plannr ledgeto help ranslate loadingforcesto
the ntetaursal
B. the meunrsal comlrnenl is a tiunium allol' hardenedu'ith ionized niu-ogenlo unprove weat
characrerisucs
C. rlrepl ^langealcoruponent (Uler-UD a.rdis arailableuilh a
is uJraldgJrnrolecularutigJtt polvetJrvlene
dunrum backtng

11. BioAcrionGreatToelmplant fir4rcroAirel

A celnenleds-\senl
B rhemeurarsalcomponenlis cobaltchromeandangJed for right andleft geomeln'1noplanur ledge)
C. the phalangeal is
conlponenl ultn high molecularseight polrethl'lenesith tiranium hacking is
arailableangled

q.af

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253
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256
Juvenil e-H allux -Abductovalgus -

-iointin personsbelos'tlreage
Dcfinirion: aberrarionin r}e functionor alignmentof t}tefirst meutarsophalangeal
of tu,ent1'.

lncidence
-Females> males
-Signifi cant positit'e familr' inhenrance(maternaluansrnission)

Etiolon'
-Autosomaldottrinance n'ith incontplelepenetrance
-Biomechanical : pesplanus/limbI engh discrepanry/STjpronalior/eguinus
-Meurarsal primus varu9adducrus
-Neurontuscular laxn
defornrities/liganrentous
-High rate of recurrence

Adult rs. irnenile HA\/

-Juyelile: lesst'algusrotationof hallui. generalabsenceof cluonictissuere:ction and degeneralive-ioinl
disease.
feq'adaprivechangesof the first MTPJ (theseare generalguidelines.but not alual's the case)

Srmrnorn-q
-Painis nol conunon
-Deformationof shoegear.difficultl'fining shoes
-Concernsith self intageand appearance (conunonpresenbtionage I l'14 1'.o.)
-Relucuncelo engagein ph1'sicalactivin
-Children.6 l'.o, rarell'haves\mplomstuzualll'presenluilh concemedparent)

Sueine of Ffst MTPJ ROM

Suge I : sligJrtabductiouof the hallu:tu,ith full ROM ald presence of dorsotuedialirriution of prominenct
Srage Il: more advanced. grealer trans\rerseplane deviation-
mavbe reducedpassivell'uithpain freeandfull
ROM
Suge III: erearerdeviatjonin tbe alipunenl of ilte firs MTPJ. ROM in defonnedpositionis full. but defonnin is
nor passivell'reducible and all anemplsto DF hallux on fim meraursalu'henlhe greatloe is rectus
resul6 in "tracking"backinto deformedposition. This is indjcativeof fixed adaptivecontraction
rr.ithirr
the firsr inrermeuursalspace.Uzuall1'u'itlr moderalelo severelateraldisplacement of sesamjods
StageIV: rare- lack of ROlvl- paiD
crepirus, in first MTPJ

Radioer'apbs
-Metaursrlsadducnrs/true
IM angle
-PASA/DASA/di sul ntetatarsal an i cular ar $ e (DMAA)
-Meuursal I engVparabola
-llallux lengrh
-Sesamoid position

Treatment
-Consen'ative:
-splints.toeu'edges.bunion shields-uider shoes
-ortboses
Surgicali ntervention:
-lndications:
-pain rapid progressionof deformiq'. severedeformiry.failure of consen'ativetrealment.
cosnreticconcerns.secondarydefornril' of the lesserdigits

257
 -Goals:
-resloralton.!nlprovetnenland presen'ationof.iointfuncuott
-reiief of pain
-resorarionof properforefootdrnamrcs
-inrprovedcosnredcapp€aranceof foot

-\\tren?
-< 6 ]'.o. : .10-50ozir of toul nreuursal grou'thrernains:srugenronll,in seyeredefonnities
-6-10r'.o. : 60-80%of meuursal Ienpnhanajnedphl,sealplare
clearlvdefinedradiographicalll..
sugen'for severedeformiq'andrn casesin u'hich significantadapuveclunges ha1,e
occurredin the anicular surfacesof the MTpJ on radiographs
- 1 0 - 1 5 1 ' . oideal
. : period:9o%oof normalmeraursallengh arujned
in mosrboysb, age l2 and
95o/"tngirls the sameage:osseous. canilaginous.and collagenouitrssues
have
relariveplasticqualiriesthal.achieveexcellenr-repair
and adapurion
-Procedures:
-sofi rissue: ineflecrive
-opemng s.edge o$eotomv of nredial culeilonu
-Lapidus
-epiphl'si odesiVepiphvseal napling
-digiral procedures: Akin
-disal firs merararsalosreoroml': Mitchell. Ausin
Rn,erdjn
{rescenlic osleolornv
-*closing base u'edge osleolonrt'*

EALLTIX LIMITUS
Definirion
a) hallui lirnirrx: d€creasein the range of motjon at tlr firsr MTpjoinr
b) haUu'; rigid:s: absenceof motjon ar firs MTpjoinr
c) normal f,rs MTP_ioint ROM: dorsiflexion -- 65-75
plantarllexion = 4O

Etiologr'
a) hypermobilefim rar
b) immobile first rav
c) excessive\'longfrm rqr'
d) frrst meuursal ele\atu
e) degenerativejoint disease
f; neoplasms
g) uauma
h) sepc art}uitis
i) iarogenic
(ie<orrecting funajornlh' ada4rd joinr u'i0r sofi tissue release:tailure to correfl pre-exisring
doniOexed
firs maaursal or abnoram[r'long firs ra1: over aggressive medial capsulorrap\': displacemenr sf
osleolonr]-.etc)
j) neuromusculardisorders
k; q'semic ayfirirides(ie-Rlg psoriaric,gou1'anhrjtis)
l) osteonecrosis seconda4'to a\"scularit_r'of metaursalhead
m) foreign bodies(ie-implanrs)

258
(,.
{
ClaSfi canoD-ofHdUrr>(L-"rffi tG-
a) prinran' r's secondan'
I. pnmaa'haliux lunjrus
>occursrn adolescent panensandis associated nith a longflrs nteuursal
>congeniulh' long firs nteuursal
2. secondaryhallux hmirus
>@cuts in ol&r paoents
>u-<uall1'caused b.\'DID.trarulla septicartluitis ands.rstemrc artluitjdes
b) srrucnual rr funcdonal
l. structuraltrallui timinrs
>dorsillexion of f.rs MTP-ioint is decreased u'lten tlrc forefmt is both loadedandunloaded
2- functional hallu:r limirus
>dorsillexionof fim MTP-iointis decrrca-sed onll' uhen t}e forefmt is loaded

Clinical Finding<
a) qmpoms
I. grad""l onsetof pain andlimiution of frn MPJ ROM
2. parn localizedto dorsalaspectof firs MTPjoint
3. parn er?erienceds'ith ambularionandprolonged rreigl$earing

b) pblsical examirlnon
l. dorsal or dorsomedialprominenceof first MPJ
(aladorsal bunion)
2. Mllui positionis mostcommonh'recor-s
3. tendenres,q uit} passivedorsillexionof hallui
4. res the fim MPJ dorsiflexions'itlr the forefmt loadedand unloaded
5. excessirt hallui IPJ dorsillexionassociated nith:
-EHL <Paqm
-ganglion c-vslor adventioush,usaassrriateds'ith EHL tendonsecondary to irriradon fiom shoegear
-planrarmedialIPJ blperkeratoticlesion
leka-pinchcallus)
6. checksesamoidmobiliq':
>load thefim ra1'andpalparctre sesamoid aparatus u'hile dorsilJexilgtbeMPJ
>arrhrodesedor fi-brosedsesamoidspr€\€Dl nornul and anv MPJ dorsiflexion
7. anralgic.aprop-rlsiwgaitu'ith an earh'heel<ff

RadiographicFindings
a) nonr.rnifonnjoint spacemrrou'ing
b) flauening of Or fi.rs meuursd head
c) oseophyes on firs meuursd headandbaseof proximal phalarx (akadorsalllag sign)
d) subchondralsclerosis
e) loosebodics(loinr mioe)q'ithin rhe frrs t4'
f; firs meutarsal elerznrs(lacral rien)
l. proxinul phalaruianiculatesuith theplarrtaraspectof &e fus meuursd head
2. bisesion of tbe frm meuursal is superiorto tlre ularbisection 0ar€ralvjeq')
g) positive meuursal prorusion disance

SurgicalManagementof llallu:i Limitus

a) objectives
l. remoral of osteopbrticqerring
2. creradonof slackin tlreflexor aPparants
3. sboneningof an excessirell'longfirs meuursil

2s9
 T
4,Lpl:l@qp*ottdan elozted firs meuursal
5. reorienuuorrof fim-nreu-rarsaf
freaOanlcuiarsuttace
I
b) joint presening procedues
I . clreijectonrv(aka--iointrenrodeling)
>remoral of oseophlncproliferationon lhe fils metaursalhe:d or baseof tlreproximal phalarui
2. Kessel& Bonnq'
r
>dorsiflexor.r'oseolonrv of baseof theproxirtralphalanr
3. Regnauld(aka-Mexicalbat procedure: enclaremenr:
autoimplant:joint decompression)
t
>baseof proxinral phalau is resectedandfasliionedinto a pegthenreluened itto ilre proxiluJ plalarui
>I-aPoru modificatjon urilizes the reseoedproximal phalangealbaseas the hole and rhe disral componenr
of the phalan:rasthe peg
I,
.1.Holunann $pe procedue

5.
>indjcatedfor longfim memnrsaietiologu
Waterman
I
>dorsifloiory oseolonr]-ofthe firsr meutarsalhead
>rhrough-and-throughosleotom\'0.5 cm proxianrJto the arricular canilage u;hjch convens planurflexon.
ROM to donifloto4'ROM
>increasesjoint ROM bt' reducingtlreinternalcubicconrenrof firsr MTP.ioinr
r
6. modified Waterman
>dorsiflotol'tredge osreolomvof theflrs meuursal hecdleavingplanur anicularcartilagem6cl
7. Waternran{reen
t
>shonens and planur0exes $e fim meuursal
>irnoh,es nro oseotomies -
-u-apezoidal urdge uider nrediallt perfonrred in dorsal to plantar drecdon
0.5 cnr proxin:al lo
I
anjollar canilage
-obUgue. Dzrnsversr osleolorm' (througb and through) 15 to the trapezoid n'hicb /
avoids the ptanrar
anicular canifage L
8. Youngsnick modificatjon of l}re Austjn procedure
9. dorsal "\l oseotol4'
I 0. plantarllexon' w-edgeosteolorm'
>Van Ness lu-anwerse oseoromll
t
>planur closing stdge osreolom'r'
I l. Conon
>openingwedgeosteolonT'ofOe medialcuneiform
(dorsaj bas"du,edgeplanrar0exes
I'
fu tA)
12.reverseC-onon
>planur basedurdge o$€olomvof tlre medialcuneiform
to dolsi0ex f,rs 4'
I
13.I-arnbrinudi
>planurllexon'u'edgeosleolotrn'ofthebasegf the firs meuursal lo corred meutaralele\?nl<
t\
14.<aglualIngrisciro
>Warcrman + L-ambrinudi

c) Joi::t desruahe proceares

I. Keller ar0roplasqr-
t
>resecrionof one-thirdof the baceof p'roximalphalaru
2. lmplant anhroplaq'
>total or bemi-implanl($'itl or uirhout gromntets)
I'
)must sutgcallv addressatryfirs meutarsal&formides for implanr rc succeed
3. Storr
I
>dorsal to planur u'edgeresectionof one-fourOrof frrst meularsalhead
t_

260
tt
t
 4. Maro
-tEicrdon
of s mnrofEs nreuurd tieaO
ilciu-arng
frtaltcrlar suflaG

5. McKee\rr arthrodesls
>firsion of meuursal-phalangeal-ioinr

6. I:pids aahrodests
>fixion of meuursal<uneifornrioint

Pos Qperatirr lr4anagement

a) biomechanical
l. onhorics
2- p&tin E accommodarirrdevices
b) continuouspassivenrodon
l. orcellentform of theraqvu'hich shouldbesaned immediatell'afiersurgen'
2. hallu:r CPM rnachrresarailable
c) intermrnentacdvemotjon
l. most commont'rpeof therapv
2. usualh'insiruredafi,eroneseek of immobili'adonposrperatirell'
3. padentis insruaed lo sabilize proxinralJr'(first nreuursal)and lo genrh'dorsil)ex/planrarllex
to tolerancefor a
fes'minutesdai\'
d) thereis no subsdrudonfor recognizingthe etiologuof the deformi\' and correcringr-heproblerr Dolju51performing
surgen lo "soolhe"s-\nlfoms
.?
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-r-\--r- t (
e ,[' f---'|rr-'-',-
CHEILECTOMY KESSEL & BONNEY 7t t{t=r-
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t r
-a .c
-=-tnr--\
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WATERMAN MODIFIEOWATERMAN

r^) Il
#a
\^{li !--e WATERIVTANI.GREEN

YOUNGSWICK
IL2U\ll f,\Y-
S P
DORSALV OSTEOTOMY 3C<NJ COTTON

26t
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VAN NESS FLANITAF'
CLOSIhJG
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u u v
(LAMBRtNUDt) JUVARA(MOD|FtED)
T
H O HlvlANNTYPE OSTEOTOMY
.{Q<) COMBINATION
-
l
(HOHMANN+ WATERMAN)
I
I
HALLTIX \/ARUS
Defnition
a) doiation oflhe hallui ar rlre frrs meranrsophalilgeal joinr
T
b) mal'exjst as a Eatls\€rse plane deformir-r'ofhallui adducnr-sor pres€nl as an adducnrs.\anl.s

l
and malleus deformin,

Classifcadon
a) congeniral hallu:i tzrus
l- pnman': an irclared deformin
2. seoon&n': associeleduith eguinorzru-s deformin' t
b) acqurred hallux rzru_<
I. sanc: muscle balance undimubed
(ie-meuursal oseor orrw)
2. drrnmic: muscular imbalance (ie,artrtrrooru-ansfer)
r
Etiologr'
a) excessivs resecrion of rhe medial eminence uir} dimrpion of the sagnal
b) medial\' sublured nbial sesamoid
€yoove
I
c) excision of the fbular sesamoid
d) overzealous medial capsulorraphl'
e) medial malposition of the sesamoid arraus afier addroor tendon Eansf,er
I
f,) musarJar imbabnce through disnrpion of both lhe addroor hallucis and lateral hcad
g) overcorrection of the intermenrarsal angle
b'o$eotorrn.
h) overcorrection of the proxima! anioiar ser angle @ASA)
i) aggressive posroperative bndagjngand qplinring
of EIIB
I
Slmpoms of Hallux Vanrs
a) hisory of IIAV surg€D'
t
b) uruble to e€ar @rventioruJshoegearcomforrablv
c) parnpresenlalongmedialaspecrof haUui secondan'toshoepressue
o pain along the medialaspecrof the arch secondaryto muscleoonracn'e
l
e) parnal the first MPJ udth or qir}orr shoegear
I
(

262 t-t
I
- Clinical SiPrrsof llallui Vanrs
;)aaau@onofrliehallul-'.---
b) contraaureat the IPi or involvingtheEHL or abductorhallucistendonstcocked-uphaliur)
c) parnon palFtion of abduoorhallucis
dt pain atld crepirusal drc fi.rstmr.
e) haUu:ilimins or rigidus

Radiognphic Sigru of}lalhut Vanrs

a) hallux addrctedal the fust MPJ
b) srakd headof first meuursal uith a peelo-ng u'bialsesamoid
c) absentfihilar sesamoid
d) previots osteolonT'ofthe firs nreuursal
e) reducedor rrgati've IM angle
I neptil'e proximal articular sel aneJe
g) arrluitic changesal $e first MPJ and/orIPJof tlrc lullu:i

Correction of Hallux Varus

a) consenztive
l. abduaoralgussrappingandspltnnng
b) surgical
l. sofi tissuerelease
>medialcapsulotorm'
> lateral capsulorrapll'
2. dvnamic sofl tissueprocedues
)abduqor hallucis tendonrransfer
>rerander a&fitaor halJucistendonlateralh
3. osseousprocedures
>correctabnormalIM angleor PASA (ie-rn'erseAustin)
4. joint dcsrlrcti\€
>artluoplaqv(ie-Keller Keller uith intplant)
>anhrodesis(ie-Md( ewer)
c) seps'ise surgcal aFproach
l. total sofi tissuereleaseat tlrc f,m MPJ
2. medial capsulotonl'
3. ubial sqsamoidecroml' (if 30-50%of t-heubial sesamoidis peekingmdia\)
4. addressabdrclorhallucisasa defornringforce(s-anderof abdrctorhallucisro dte planur-lateralllexor
aFpanrusand larcralbaseof the proxinnl phalanx)
5. osseouscorrection
>determineOrelorel of the osseous deformin
>rB'rse tbe prn'ious firs meuursal ofleorcrlD'
>if the IM angleis negath'e-musl rE\€rsetheovercorrectionu'ith appropriateoseolom]'
(ie-reverseAustLL ts/erse Oft€t V. reverseCBWO)
6. arrluoplaqv of rhefi,m MPJ for soreredeformiq'andfor non-funcdonaljoint surfaces
>Keller
>Keller ud0r hemi-implaruor total implarn
>Keller q'irh fusion of halhurIPJ
7. anhrodesisof tle fi.rs MPJ
>McKeg'er
>IJpd,is

263