lesser toe procedures

Girdlestone-Taylor procedure

· make 5 mm transverse plantar incision in proximal flexor crease

· blunt dissect out flexor tendon sheath

· open flexor sheath and elevate out central FDL tendon

· make second transverse plantar incision in distal flexor crease

· release FDL from base of distal phalanx

· deliver FDL through proximal plantar incision

· split FDL longitudinally

· make dorsal longitudinal incision over proximal phalanx

· expose extensor hood

· make 3 mm longitudinal incision in each side of extensor hood halfway between midline and edge

· on each side, pass artery clip through dorsal incision in extensor hood to plantar incision keeping close to bone

· pass each half of FDL dorsally

· place ankle in neutral and PIP joint in 20^o plantarflexion

· suture tendons to either side of extensor expansion or to each other under slight tension

· should be no residual deformity

· short leg cast with toe platform for 4 weeks

PIP joint excision arthroplasty or arthrodesis

· make dorsal elliptical incision over PIP joint

· excise ellipse of

· thickened skin

· extensor tendon

· joint capsule

· release collateral ligaments

· hyperflex toe to expose proximal phalanx

· for arthroplasty

· excise head and neck of proximal phalanx

· for arthrodesis

· excise head of proximal phalanx

· flatten base of middle phalanx

· insert wire across PIP joint

· insert wire through base of proximal phalanx out toe

· insert wire across PIP joint

· close skin as dermatodesis

· surgical shoe

· remove wire at 3 weeks

MTP joint hyperextension correction

· perform percutaneous extensor tenotomy first

· hyperflex toe and check position

· if MTP joint extension not corrected, open procedure

· make longitudinal dorsal incision over MTP joint

· release long and short extensor tendons

· make transverse incision in dorsal joint capsule

· hyperflex toe and check correction

· if correction insufficient, release collateral ligaments

· if correction still insufficient, decompress MTP joint

· options are resection of part of MT head or PP base

· expose MTP joint

· excise enough of MT head or phalanx base to allow correction

· hold correction with longitudinal K wire

· same wire as across PIP joint above if applicable

· surgical shoe

· remove wire at 3 weeks

Metatarsal osteotomy

· make longitudinal incision over distal MT

· expose distal shaft and neck

sliding

· make oblique osteotomy starting proximally and finishing distally

· displace osteotomy by pushing MT head through sole

· fix with K wire

dorsal closing wedge

· excise wedge of bone from distal shaft

· leave plantar cortex intact

· close wedge by pushing on MT head through sole

Forefoot reconstruction

kates procedure

· mark metatarsal heads

· mark plantar ellipse around them

· excise skin ellipse

· approach each MT head longitudinally by incising bursa and volar plate

· if flexor tendons not subluxed, open flexor sheath and retract them

· expose the sides and dorsum of the MT heads

· remove MT head, neck and distal shaft

· begin medially and proceed laterally in cascade

· leave each MT head 2-3 mm shorter than previous one

· resect more of 5th MT to avoid excessive weight bearing

· remove all spikes and loose fragments

· manually correct lesser toes

· optionally insert K wires along toes

· remove sesamoids if symptomatic

· close skin to pull plantar fat pad proximally

modified fowler technique

· make 2 parallel longitudinal dorsal incisions

· between 2nd and 3rd MTs

· between 4th and 5th MTs

· divide both extensor tendons

· open each MTP jt through transverse incision

· expose each MT head

· deliver 2nd MT head by plantarflexing toe

· remove MT head, neck and distal shaft

· if not possible, osteotomise distal MT shaft first

· resect each MT head to create gentle cascade

· remove all spikes and loose fragments

· close wound