Chapter 26: Digital Deformities and SurgeryHammertoe SyndromeMallet Toe SyndromeClaw ToeOverlapping 5th ToeHallux HammertoeHallux Interphalangeal ArthrodesisLesser Digital ArthrodesisOverlapping 2nd ToeSyndactlyizationDigital ImplantsFloating Toe SyndromeBlue Toe SyndromePolydactylism

DIGITAL DEFORMITIES ANDSURGERY

Hammertoe SyndromeThere is a necessity for surgical procedures not only to relieve symptoms, but also to preserve function. The toe functions to decelerate the foot, stabilize, help in propulsion, and for kinesthetic sensation. To prevent a recurrence, it is necessary to investigate and neutralize the deforming forces for full correction of the deformity

1. Definitions:a. Hallux hammertoe: This is a deformity whereby there is a dorsal contracture of the 1st MTP joint and a plantar contracture of the hallux IPJ. There is a dorsal contracture of the MTP joint capsule and plantar contracture of the hallux IPJ capsuleb. Lesser hammertoe: Plantarflexion of the PIP joint with dorsiflexion of the MTP joint.c. Clawtoe: Dorsiflexion of the MTP joint and plantarflexion of the DIP and PIP joints.d. Mallet toe: Plantarflexion of the DIP jointe. Clinodactyly: Curly toe (transverse plane deviation) f. Digiti quinti varus: Overlapping 5th toe

2. Classification: Digital deformities are classed according to their flexibility. This is determined by dorsiflexing the MTP joint and noting the amount of reduction of the digit (Kelikian push up test) at the MTPJ a. Flexible: Reducible on weight bearing and with the push up test b. Semi-rigid: Slightly reducible by handc. Rigid: No change in the deformity when examiner attempts manual correction

3. Anatomy: Electromyographic studies have shown that the long flexor fires approximately at 15% of stance phase, the short flexor at 60%, the EDB at 40%, the EDL during swing and heel contact, and the intrinsics (interossei) at 50%.a. Extensors:i. The EDL goes to each lesser digit by a separate tendonii. The EDB goes to the middle three lesser toes EDL and EDB form a common tendon that passes over the proximal

phalanx to split into three slips. The middle slip goes to the middle phalanx and the lateral two rejoin to insert over the distal phalanx

The sling apparatus is part of the extensor hood. The sling mechanism wraps around the base of the proximal phalanx and attaches to itself. It can lift up on the proximal phalanx like a sling. There are no specific attachments of the extensor apparatus into the proximal phalanx

The EDL and EDB dorsiflex the MTP joint by the sling and cause weak extension of the DIP and PIP joints, but in vivo cause passive flexion due to the passive stretch on the fibers.

b. Flexors:i. Goes to each digit to insert on the distal phalanx after passing deep and superficial through the FDB under the proximal phalanx. It has the quadratus plantae attached to its lateral border to help align its pull and the four lumbricals attached distally and medially.ii. The FDB is a 1st layer muscle that goes to each toe and inserts on the middle phalanx. Flexor tendons do not insert on the proximal phalanx

Action of the FDL and FDB gives active flexion of the IPJ's and secondary passive extension of the MTP joint from the passive pull on the extensor complex

These are stance phase muscles that help in stabilization and propulsion of the foot and digits

Predominant action of the brevis vs. longus may determine whether the PIPJ or DIPJ is contracted

c. Intrinsics:i. There are 4 dorsal interossei. They abduct the digits around a central ray. Their insertion is on the medial side of the 2nd and the lateral side of the 2nd, 3rd, and 4th proximal phalanx. There is also a point of attachment of both plantar and dorsal interossei to the plantar plate under the MTP joint.ii. Plantar interossei are 3 in number. They adduct the 3rd, 4th and 5th digits toward the 2nd by attaching to the medial side of the phalanx and plantar plate. The interossei run dorsal to the deep transverse metatarsal ligament, but

inferior to the axis of flexion of the MTP joint, and both function to plantarflex the MP joint and extend the PIPJ and DIPJ

When both interossei on each side of the MTP joint fire concurrently, transverse plane abduction/adduction is stabilized

These are stance phase muscles that help prevent buckling of the toes due to the mechanism of the sling and production of passive stretch on the longer extrinsic muscles

iii. Lumbricales are 4 muscles that originate from the medial side of each of the 4 FDL tendons, run beneath the deep transverse intermetatarsal ligament to insert into the base of the proximal phalanx and form the distal extent of the extensor expansion. They plantarflex the MTP joint and dorsiflex the PIPJ's and DIPJ's Not recorded on EMG By limiting dorsiflexion of the MTP joint they help hold the digit in a more

rectus positioniv. Quadratus plantae is attached to the FDL laterally coming off the calcaneus. Its proximal pull helps align the FDL pull to reduce the adductovarus component to the lateral digits.

d. Arterial and venous supply:i. The majority of the arterial supply is via the medial plantar arterydigital branches to each digit.ii. Dorsally the digits are supplied by the dorsal digital proper branchesiii. The venous supply runs parallel to the arterial supply

e. Neurological supply: Divided into plantar and dorsal i. Dorsal aspect: Saphenous nerve runs on the medial aspect of the foot to the 1st MTP joint The deep peroneal nerve supplies the adjacent sides of the lateral and

medial aspects of the 1 st and 2nd toes The medial dorsal cutaneous branch of the superficial peroneal nerve

supplies the medial aspect of the hallux and the contiguous sides of the 2nd and 3rd digits

The intermediate dorsal cutaneous nerve from the superficial peroneal

nerve supplies the adjacent sides of the 3rd and 4th digits, and the 4th and 5th digits

The sural nerve supplies the lateral aspect of the dorsum of the foot and the lateral aspect of the 5th digit

ii. Plantar aspect:

The medial plantar nerve of the posterior tibial nerve supplies the hallux, 2nd, 3rd, and medial aspect of the 4th digit

The lateral plantar nerve supplies the lateral aspect of the 4th and 5th digit

f. Summary: i. Stance: FDL and FDB are deforming digital forces, but the FDB is the primary

deforming force Interossei and lumbricales have the potential for stabilizing the MTP joint

and neutralizing the deforming forces With intrinsic pathology, hammertoes form When the intrinsics function properly, stable digital function ensues Interossei are stance phase, lumbricales are not well documented (swing

phase hypothesized) ii. Swing: EDL and EDB are active deforming forces that could create a hammer toe

in swing phase by creating MTP joint dorsiflexion and passive plantarflexion of the IPJ's

It is assumed in normal foot function, that lumbricales prevent hammertoes from occurring

4. Etiology: The etiology of the hammertoe will depend to a degree on the time in the gait cycle when the toe becomes initially deformed. There are 3 basic mechanisms.

NOTE* These all have a common mechanism: abnormal extention of the proximal phalanx and secondary passive stretch of the flexors and flexion of the PIPJ's and DIPJ's

a. Flexor stabilization: Is an increased pull of the long flexors as they gain mechanical advantage over the intrinsics due to i. Early flexor firing to help stabilize the hypermobile and flat footii. Intrinsic pathology This is a stance phase condition seen from midstance on The foot is flexible and forefoot abducted The long flexors are firing early and longer to stabilize a pronated mobile

forefoot The intrinsics are not able to counter the deforming forces so hammertoe

deformities develop The flattened foot may come from forefoot varus, equinus, calcaneal

valgus, torsional problems, muscle imbalances, ligament laxity, and neuromuscular problems

Adducto-varus deformity of the 5th and sometimes the 4th toes

b. Extensor substitution: Is a swing phase condition due to weak anterior muscles (due to ankle equinus, weak lumbricales, and spastic EDL)i. Marked dorsiflexion of the MTP joint that may straighten on ground contact. The extensor tendons and the metatarsal heads are prominentii. Progresses to a rigid deformity with timeiii. The extensors gain a mechanical advantage over the intrinsics (lumbricales) when the anterior muscles are firing to dorsiflex the foot at the ankle in swing to gain ground clearance and at heel contact to prevent foot slapiv. Patients may be diagnosed NWB by having them dorsiflex their foot. Normally the digits will dorsiflex approximately 300 at the MTP joints. With extensor substitution there will be more dorsiflexion of the proximal phalanxv. Extensor substitution can occur in an equinus foot. There is an increased declination of the front part of the footvi. Even though the digits are rectus on weight-bearing, during swing they curlvii. Results in an anterior pes cavusviii. Whatever will allow the long extensors to fire early or gain a mechanical advantage over the lumbricales will result in extensor substitution

c. Flexor substitution: Occurs where there is weakness of the triceps surae.i. The posterior deep muscles and the peronei attempt to produce heeloff in place of the weakened triceps. This may be due to overlengthening of the achilles or a congenital problem.ii. A calcaneal gait is commoniii. Produces a hammertoe deformity without the adductovarus componentiv. A supinated high arch foot type is seen

5. Preoperative considerations:a. If the Kelikian push-up test allows the digit to straighten, then the EDL and MTP capsule is not so taut so that only a flexor tenotomy may be done

b. 90% of the hammertoe deformities are a result of FLEXOR STABILIZATION compensation secondary to hypermobile flat feet.Therefore following surgery orthoses must be used to neutralize the etiologyc. With EXTENSOR SUBSTITUTION an arthroplasty would only be temporary due to lack of neutralization of the deforming forces, soft tissue releases would only add a little time, and orthoses function during stance phase and won't work here. Therefore an arthrodesis is the procedure of choice. A Hibbs procedure would only be useful in a flexible deformity d. With FLEXOR SUBSTITUTION strengthening of a weakened triceps by tendon transfer and fusion of the digits would be in order

6. Surgical procedures:a. Post procedure: Arthroplasty with proximal head resectionb. Lambrinudi procedure: Fusion of PIP and DIP joints c. Young-Thompson procedure: Peg-in-hole fusiond. Gotch procedure (or Gotch and Kreuz): Resection of the base of the proximal phalanx and syndactylization of the digitse. Girdlestone procedure: Transfer of the flexor tendons to the dorsum of the proximal phalanxf. Sgarlato procedure: Transfer of the FDL dorsally with capsular resection through a 3 incision approachg. Taylor procedure: PIPJ arthrodesis using a K-wireh. Hibbs procedure: A tenosuspension transferring the EDL to the met heads or base conjointlyi. Collins procedure: Repositioning of the medial and lateral extensor slips dorsally on the digitsj. Suppan CAP procedure: Indicated for hammertoe correction in children. Two transverse semielliptical incisions are made over the head of the proximal phalanx, skin section and tendon and capsule removed, the collaterals are left intact, metaphyseal osteotomy performed with cylinder of bone removed. The capital fragment will fit snugly against the shaft of the proximal phalanx and held snugly by the skin repair

7. Correction of the non-reducible hammertoe: Know the etiology and neutralize it and follow a stepwise approach during surgery.a. Arthroplasty to release PIPJ pressure and reduce the corn. Now do the Kelikian push up test. (If the toe still does not straighten go to the next procedure)b. Extensor recession for release of the hood and sling fibers to slacken the extensor apparatus to the proximal phalanx: If the toes still does not straighten go to the next procedure

c. Hood release or EDL lengthening: If no straightening go on to the nextprocedured. Capsulotomy of the MTP joint: If no straightening go on to the next

NOTE* When doing this do not cut the lumbricales to the base of the proximal phalanx

proceduree. Plantar hood releasef. If a problem still exists fuse the PIPJ with a K-wire and extend through the MTP joint held in a rectus position: Allows the digit to function as a rigid beam and the deforming flexor to pull the entire toe into plantarflexion

8. Correction of reducible hammertoe deformity:a. Flexor tenotomy: When there is a flexion at the PIPJ which can be reduced, the long flexor tendon may be the only pathological entity which needs correction. If the skin is contracted, it is done through a plantar incision, otherwise done through a medial or lateral approach.b. Extensor tenotomy and capsulotomy: When the extensor tendons are contracted along with the dorsal capsule of the MTP joint, this may be the only pathological entity which needs correction. Care is made not to injure the cartilage of the joint. The toe is splinted for 4-6 weeks.

c. Repositioning of the extensor slips: In digits in which the PIPJ is buckled but completely reducible, the medial and lateral extensor slips may be repositioned dorsally on the digits.

9. Complications:a. Floppy digit with phalangeal base resection b. Edema and sausage toe c. Floating toe with metatarsalgiad. Short toee. Regeneration of the phalangeal head f. Infectiong. Decreased sensationh. Blue toe secondary to venous congestioni. White toe secondary to arterial spasm

NOTE* The difference between a floppy (flail) toe and a floating toe is that a floating toe does not purchase the ground while a floppy toe may purchase the ground however it is unstable.

NOTE* Test the proximal phalanx for any dorsal resistance after each step. If the proximal phalanx springs dorsally after it is placed in a corrected position, go on to the next step

NOTE* It is important to lengthen both the long and short extensors

NOTE* By performing this procedure, one avoids resection of bone, shortening of a digit, and flailness. The toe becomes straight, but very little motion is present at the IPJ.

Mallet Toe SyndromeA sagittal plane deformity in which the distal phalanx is flexed on the middle1. Surgery (adults):a. Two semi-elliptical incisions encompassing the middle phalangeal head will allow good access for resection of this deformity b. Must be careful of the neurovascular structures with this procedurec. Usually the deforming forces emanate from the contracture of the FDL or abnormal morphology of the bony middle phalanx 2. Surgery (children):a. Suppan CAP procedure: Performed similar to the hammertoe procedure, except the metaphyseal osteotomy is done at the head of the intermediate phalanx, and no subcutaneous sutures are used

1. Definition: Dorsiflexion of the proximal phalanx with plantarflexion of the middle an distal phalanx

2.

Surgery of severe claw toe with MPJ deformity:a. Incision from DIPJ to metatarsal neck (curving across the metatarsal neck)b. Z-plasty EDL and retractc. Prepare bone for arthrodesis (now do Kelikian push up test) d. Extensor hood release (Kelikian test)e. Capsulotomy at MPJf. Fuse toe with K-wire across the MPJg. Repair EDLh. If medial or lateral dislocation of the flexor plate present, you will need capsulorrhaphy on one side of the MPJ

Adductovarus 5th Toe Deformity (overlapping 5th toeThis condition is usually hereditary and present most often bilaterally. Before a procedure is done it is necessary to determine if any functional adaptation has taken place in the 5th MTP joint. If this has occurred it is then necessary to perform an osseus procedure (adults only). If there is any skin contracture, a plastic release must be additionally performed 1. Etiology:a. Proximal phalangeal base removed b. Intrauterine positionc. Result of tailor's bunion procedure (tissue contracture) d. Short EDLe. Hammertoe toe repair sequelae

2. Diagnosis:a. Adduction of the toeb. Contracture of the MTP capsule

c. Medial contracted EDL d. Varus rotatione. Extention of MTP joint f. Subluxed MTP joint

3. Surgical planning: a. Skin incisions: i. Z-plasty or V-Y

ii. Plantar ellipticaliii. Plantar V-Yiv. Longitudinal incisions with dog ear resection v. Syndactylizationb. Tendon/soft tissue:i. Release and lengthening of the EDL ii. Capsulotomyiii. Plantar capsule releaseiv. Transfer EDL to distal stump of abductor digiti quinti

NOTE* The central arm of the Z-plasty is in line with the direction you want to lengthen the skin

v. Suspend EDL tendon around the metatarsal neck v. FDL split and reattached dorsally c. Bony procedures:i. Resect 5th metatarsal headii. Proximal phalangeal head removaliii. Removal of the base of the proximal phalanx iv. Abductory wedge removal of phalanx v. K -wire to hold position4. Procedures:a. Lapidus procedure: Extensor tenotomy with transfer of the distal stump under the proximal phalanx to attach to abductor digiti quintib. Kelikian procedure: Syndactyly of the 4th and 5th after capsule release

and arthroplasty of the 5th toec. Ruiz Mora procedure: Resection of the proximal phalanx and semieliptical plantar crease incisions to hold in corrected positiond. Lanzonis procedure: Extensor tenosuspension of the 5th metatarsal head and fusion of the PIPJ and MTP capsulotomy e. Goodman-Swisher procedure: A V-Y plasty, Z-tenotomy and capsulotomyf. Butler procedure: Two concurrent racket shaped incisions completely encircling the toe so to derotate and plantarflex g. McFarland procedure: Proximal phalangeal head removed, Jones suspension and syndactylizationh. Jahss procedure: Ruiz Mora incision with diaphesectomy of the proximal phalanx

Hallux Hammertoe Deformity1. Etiology:a. Muscle imbalance seen with a cavus foot typeb. Following surgical procedures of the 1 st MTP jointi. Especially with removal of both sesamoidsii. Detachment of the flexor brevis tendons at their insertion onto the base of the hallux tendonsiii. Overzealous HAV surgery with medial subluxation of the tibial sesamoidc. In the presence of IPJ sesamoids which bind down the long flexor tendon in a shortened position2. Flexible deformity: An IPJ fusion with EHL lengthening may be done, approached through 2 semi-eliptical incisions,

NOTE* In a child osseous procedures usually do not have to be performed. A Zplasty or V-Y plasty may be utilized to release the skin contracture. An extensor tenotomy at the level of the MTP joint and capsulotomy are performed. A plantar skin wedge can be removed. Toes are splinted for 4 weeks

NOTE* In adults it is usually necessary to perform an osseous procedure at the level of the MTP joint. If the base of the proximal phalanx is resected, then syndactylism of the 4th and 5th digits should be performed. If a partial metatarsal head resection is performed, then a Z-plasty or V-Y skin plasty is performed. Some also advocate the removal of a transverse skin ellipse plantarly to help hold the toe in position

NOTE* Fixation for fusion is either with 2 K-wires, AO fixation (4-0 cancellous, 3.5 cortical, 2.7 cortical), or 28 gauge monofilament wire loops

3. Rigid hammertoe deformity: Jones tendon transfer plus IPJ fusion

4. Rigid hammertoe deformity plus rigid plantarflexed 1st ray: IPJ fusion plus dorsal wedge osteotomy of the 1st metatarsal

4. Postoperative complications:a. Non-unionb. Hallux limitus or rigidusc. Hallux extensusd. Elevatus of the first metatarsal with IPK sub 2nd metatarsal

Hallux Interphalangeal Arthrodesis1. Fixation techniques:a. Stainless steel monofilament wire, 28 gauge b. Two 0.045 Kirschner wires c. 4.0 cancellous screw d. 3.5 cortical screw (lag) e. 2.7 cortical screw (lag)

2. Indications for fusion:a. Semi or non-reducible IPJ contractureb. Hyperkeratosis overlying the IPJc. Transverse or frontal plane deformity of the hallux d. Clawtoe deformitye. Abnormally long or short toe

Lesser Digital Arthrodesis1. Biomechanics:a. Flexor substitutionb. Extensor substitution

2. Signs and symptoms:a. Semi-rigid or rigid deformity b. Dorsal hyperkeratosisc. Transverse plane deformity may be present d. Clawtoe deformity may be presente. Abnormally long or short toe may be present f. Painful PIPJ motion may be present

NOTE* AO fixation of the IPJ cannot be used with a total joint replacement unless 2.7 mm cortical screw modification is utilized, but can be difficult

NOTE* Monofilament wire fixation and crossed K-wires are the best choices when planning to utilize a total joint replacement

NOTE* When doing an IPJ fusion, the propulsive phase of gait should be eliminated for 6 weeks

g. Flail toe secondary to previous surgery3. Fixation:a. Stainless steel monofilament 28 gauge wire loops b. 0.045 K-wirec. Reese arthrodesis screwd. Orthosorb®

NOTE* Fusion of the 2nd toe will not stop the formation of a hallux abductus deformity

Overlapping 2nd Toe1. Etiology:a. Chronic biomechanical forcesb. Intra-articular steroid injectionsc. Inflammation of the joint capsule (seen with RA)

2. Surgery:a. Resection of phalangeal baseb. Flexor tendon transfer c. Proximal IPJ arthrodesisd. Partial met head resectione. Relocation of the flexor platef. Freeing the base of the proximal phalanx from attachments and freeingthe metatarsal head from attachments and fixating with K-wireg. Repositioning of a 2nd MTP capsular flap h. Total implant arthroplasty

Syndactylization1. Classification:a. Type 1 (zygodactyly): Most commoni. 2nd and 3rd digits most frequently involved (followed by the 3rd and4th digits)ii. Asymptomatic and requires repair primarily for cosmetic reasonsb. Type 2 (synpolydactyly):i. Associated with duplication of a part or entire digit (the duplicated digitusually intervenes between two essentially normal digits)ii. 3rd and 4th digits primarily affected, followed by the 4th and 5thtoesiii. Usually discomfort due to shoe irritation when the 5th toe is involvedc. Type 3: Fingers only d. Type 4: Fingers only e. Type 5i. Syndactyly with concomitant metatarsal (or metacarpal) synostosis

2. Surgery: Plastic flap repairs (see following diagram)

Digital Implants1. Signs:a. Deformity involves the 2nd and or 3rd toe at the PIPJb. Semi-rigid or rigid hammertoe deformityc. Painful PIPJ motion may be presentd. Hyperkeratosis may be presente. Involved toe is of normal or shortened length when placed in its properpositionf. Absence of significant MTP joint or DIP joint contracture of the involvedtoeg. Absence of significant frontal plane deformity of the involved toeh. Normal skin condition, vascular status, and neurological status

2. Radiographic findingsa. Adequate bone stock to receive the stems of the implant

b. Adequate width of the proximal and intermediate phalanx to receive the stems of the implantc. Adequate length of the intermediate phalanx to receive the stem of the implantd. Absence of MTP and/or DIPJ contracturee. DJD of the PIPJ may be present

3. Implant product selection:a. Silastic H.P. 100, (Swanson Type) Weil Design, Dow Corning Wright:A double stemmed flexible implant with cylindrical central bodyb. Sutter Lesser Toe Proximal Interphalangeal Joint Prosthesis (Sgarlato Design), Sutter Biomedical: A double stemmed very flexible implant with a central hinge and rectangular stems with a polyester mesh internal fabric for reinforcementc. Sgarlato Hammertoe Implant Prosthesis, Sgarlato Labs: The newest device, also a double stemmed with a trapezoidal solid central portion

4. Implant procedure:a. Two longitudinal semi-elliptical incisions (to prevent fat toe syndrome) b. The dorsal tendinous structure is dissected free from the base of the distal phalanx to the middle of the shaft of the proximal phalanx, and is retracted medially or laterallyc. The PIPJ is entered by severing the capsular ligamentsd. The head of the proximal phalanx is excised at the surgical neck (a little more bone is removed than with a traditional arthroplasty) e. The proximal phalangeal stump is reamed first, and the middle phalangeal stump is reamedf. The implant is inserted, and there should be a 2-3 mm space between the implant and each bone (very important)g. The tendon and skin are then repaired

5. Advantages of digital implants:

a. Relief of painb. Maintenance of toe stabilityc. Maintenance of toe lengthd. Restoration of functione. Allows for PIPJ motion and plantar gripping power of the toe f. Minimal postop disability and early toe motion

6. Disadvantages (versus regular arthroplasty):a. Cannot be performed in an abnormally big toeb. Difficult to perform in the 4th and 5th toe due to small bone stock

c. Need good bone stock and adequate width of boned. Need to have normal. sagittal plane position of the MTP joint e. Needs specialized equipmentf. Cannot be used with frontal plane deformityg. Need to remove implant if infection occursh. The Silastic Swanson design could permit lesion recurrence and digital swelling due to the large diameter central portioni. The Sgarlato implant is also available in a longer stemmed version which is useful in revisional surgery as well as digits with longer phalanges

7. Contraindications:a. Nonreducible contracture of MTP joint and/or DIPJ of the involved toe b. Inadequate bone stockc. Infectiond. Inadequate vascular statuse. Significant frontal plane deformityf. Presence of an implant at the MTP joint of the involved toe g. Inadequate skin coverage

Floating Toe Syndrome1. Etiology:a. Bradymetatarsiab. Excessively elevated metatarsalc. Dislocated flexor plated. Procedures which reduce the internal cubic content of the joint e. Resection of the base of the proximal phalanx

2. Surgery:a. Correct the underlying etiology b. PIPJ fusion

NOTE* The Sgarlato (S.H.I.P.) and Sutter device have been used in the 5th toe due to their size.. The Sutter which has the advantage of having a small central portion whose thickness is less than its width, can be placed either angled or vertical to prevent pressure from the shoes or adjacent tissues. The S.H.I.P. can be placed normally

c. Total joint replacement

Blue Toe Syndrome1. Definition: Blue toe syndrome/purple toe syndrome results from atheromatous embolization, which can eventually lead to gangrene if the cause is not eliminated

2. Causes:a. Atherosclerosis (most common)i. Thrombosis formation, b. Infectioni. Microthrombi formationii. Secondary syphilis c. Atheroembolismi. Cholesterol emboli from ulcerated plaques in the more proximalvesselsii. Mural wall thrombi iii. Endocarditis iv. Myxoma v. Vascular surgery vi. Angiography vii. Meningitisd. Anticoagulation i. Coumadine. Thrombolytic activityi. Tissue plasminogen activator ii. Streptokinasef. Drugsi. Dopamineii. Beta blockers iii. Steroidsiv. Epinephrine (in local anesthetics)g. Hyperviscosity syndromes i. Cryoglobulinemia ii. Cold agglutinins iii. Polycythemia verah. Hypercoagulable states i. Malignancies ii. Diabetes mellitusi. Vasculitisi. Polyarteritis nodosa group ii. Hypersensitivity groupii. Wegener's granulomatosis group iv. Giant cell arteritisj. Foot surgery

3. Signs and Symptoms: a. Pain

b. Bluish mottling of the digitc. Pedal pulses tend to be presentd. Can be either bilateral or unilateral

4. Origin of the Emboli:a. Bilateral signs and symptoms in the toes suggests ulcerated plaques in the aorta.b. Unilateral signs suggests ulcerated plaques in the iliac, femoral, ofpopliteal arteries.

5. Treatment:a. Angiography to determine the location of the plaque b. Photoplethysmography of the digitsc. Removal of the atheromatous plaqued. Endarterectomyd. Risk factor modificatione. Amputation as necessaryf. Medical therapy as needed (i.e. D/C anticoagulant or other suspected causative agent, use of antibiotics or other drug)

PolydactylismA hereditary malformation, transmitted as an autosomal dominant trait. It may occur as a single deformity in the foot (nonsyndromatic) or may be associated with accessory digits in the hand, and there may be other congenital malformations as well (syndromatic). The digital deformities may be pre-axial (hallux) or post-axial (5 toe) or central toes 2,3,4). The duplication of the toe may be complete or involve the distal phalanx or the distal and middle phalanx. The metatarsal may be partially or completely duplicated. Duplicated digits may share a common metatarsal. Shoe fit is the major problem.1. Classification (Temtamy and McKusick): Adapted from the classification of the hand (less applicable to the foot)a. Pre-axial:i. Type 1 to type 4b. Post-axial:i. Type A: A fully developed accessory digit that articulates with either the 5th metatarsal or with a duplicated 5th metatarsalii. Type B: Characterized by an accessory digit devoid of osseous tissue which represents a vestigal digit

1. Surgical tenets:a. The most rudimentary digit (least important) should be excised when possible leaving 5 toesb. Try to achieve a normal functioning foot as well as a cosmetically pleasing onec. Avoid scar on the medial or lateral side of the foot where shoe pressure will

NOTE* Venn-Watson further divided postaxial polydactyly into 5 specific morphological patterns, based on the degree of metatarsal duplication

irritate them

2. Surgical excision of lateral pre-axial toe:

a. If any other congenital deformities are present, they should be corrected first

b. The above diagram shows an accessory pre-axial great toe that is in varus secondary to a metatarsus adductus. The metatarsus adductus is treated first via casting (which will help stretch the medial skin of the hallux prior to surgery). In the above case it is best to remove the lateral toe so the scar line is on the lateral aspect. Redundant soft tissue can be excised from the 1st interspace, and the adductor hallucis stump from the amputated toe is sutured to the base of the remaining proximal phalanx, and the intermetatarsal ligaments are repaired. This helps straighten the toe and close the intermetatarsal angle

3. Surgical excision of a medial postaxial toe:a. The following diagram illustrates the lesser developed medial 5th toe. Excision is made via two longitudinal eliptical incisions around the accessory 5th toe which meet at approximately midshaft of the 5th metatarsal