RU2736907C1 - Method for surgical correction of iatrogenic extension of hallux - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention refers to medicine, particularly to orthopaedics, and can be used for elimination of iatrogenic postoperative extension arising as a result of excessive shortening of the first metatarsal bone. Skin incision is made along the medial surface of the metatarsophalangeal joint and an attachment point of the abdominal tendon is selected. Then, the proximal end of the tendon is dissected longitudinally in the proximal direction to the muscular portion, forming a split graft, wherein the size of the excised tissues is determined so as to provide plantar flexion of the finger and its subsequent fixation. Formed part of tendon flap of abductor is delivered through muscular part of short and long flexor of first finger in the plantar direction with subsequent fixation to a muscle-tendon part of short flexor 1 finger in correction position 1 fingers interrupted or continuous sutures.EFFECT: method allows visual control of fixation point of tendon flap of abductor and required position of finger, by forming split splint of tendon abductor and its further through muscular part of short flexors of first finger with subsequent fixation to them, and tension of the tendon flap of the abductor eliminates extensive deformation, prevention of deformation recurrence is ensured by stable position of the nail and middle phalanges of the first finger firmly fixed by the abdominal tendon.1 cl, 1 ex, 5 dwg

Description

The invention relates to medicine, in particular to orthopedics, and can be used to eliminate iatrogenic postoperative extension arising from excessive shortening of the first metatarsal bone.

First (1) toe extension is a condition faced by every foot and ankle surgeon. The urgency of this problem is due to a significant decrease in the quality of life of this group of patients associated with a constant, minor pain syndrome, problems with the selection of shoes, instability when walking and running, as a result of progressive dysfunction of walking and support. Extension of 1 toe can occur both as a result of iatrogenic effects, and as a result of neuromuscular lesions.

Causes of extension deformity of the first toe:

- Excessive shortening and / or lowering of the first metatarsal bone (M1) during forefoot reconstruction.

- the development of extension after injuries of the plantar plate 1 of the PPS (turf toe).

- extensions after postponed tendinitis and tendinopathies.

- extension against the background of spastic and neuromuscular lesions.

The manifestations of this pathology can vary from aesthetic and visual discomfort and 1 fingers sticking upward, to traumatic and fungal lesions of the nail bed. Often there are complaints of persistent chronic pain in the metatarsophalangeal joint. A number of patients noted a violation of the static-dynamic function during walking and running.

Types of treatment for this pathology:

The proposed conservative methods of treating this pathology include options for a variety of methods for eliminating the extension of 1 finger or alleviating symptoms:

1. Making special shoes with the exception of traumatizing the nail bed.

2. Making special insoles - orthoses with a metatarsal roller, which reduces the overload of 2-3-4 fingers, relieves the symptoms of the disease.

3. The use of bandages and semi-rigid orthoses contributing to the temporary elimination of the extension

Conservative treatments do not solve the problem, but rather relieve symptoms.

Known methods for the surgical treatment of extension deformities of the first toe, introduced by Bernard Regnauld, and described by him in the book, The FootSpringer-Verlag Berlin Heidelberg, Springer, Berlin, Heidelberg, pp. 287-289. 1986.

Known methods include tendon, bone and combined methods of eliminating deformities associated with osteotomies at various levels and arthrodesis of joints.

However, the known methods have a number of significant disadvantages. As a result of increased trauma and working with bone-tendon complexes, there is a risk of aseptic and septic complications, the risk of extensive postoperative adhesions and strictures. Most of the methods include arthrodesis of the distal joints, which cannot but affect the patient's quality of life.

The currently accepted method is to perform a needle, percutaneous tenotomy of the extensor of the first toe and capsulotomy of the metatarsophalangeal joint of the first toe, described by Acero Caballero J: Aguilar Lopez A: Sovillano FJ. Hospital de la Frontera (55 congreso SECOT). The method includes the following techniques: puncture the skin with a needle or a thin scalpel in the projection of the extensor tendon at the level of the metatarsophalangeal joint, complete transection of the tendon and dissection of the joint capsule with further manual immobilization of the first metatarsophalangeal joint. This technique is aimed at eliminating the extension deformity of the first toe.

However, this method of surgical correction has a number of significant disadvantages. With the elimination of the extension due to percutaneous, teno- and capsulotomy, it is not possible to achieve a complete correction of this pathology, and there is also no permanent stable position of the distal fragment in the correction position. Which often leads to a relapse of the extension or not completely eliminating it. Also, do not forget that often the occurrence of an adhesive process in the tendon - surrounding tissue - near the tendon structures leads to a recurrence of the extension.

The closest analogs from the prior art have not been identified.

The technical result achieved using the proposed invention is a reliable and stable elimination of the extension of the first toe, early mobilization of joint movements, controlled plant flexion of the finger and the absence of the need for transarticular fixation, arthrodesis of joints and osteotomies.

The technical result is achieved by the fact that in the method of surgical removal of iatrogenic, intraoperative extension of the first toe, a skin incision is made along the medial surface of the metatarsophalangeal joint, the attachment site of the abductor tendon is isolated, then the proximal end of the tendon is cut longitudinally, forming a split graft, and the size of the excised tissues is determined in such a way that to provide adequate plantoflexion of the finger and reliable fixation in a given position, then the formed part of the tendon flap of the abductor is passed through the muscular part of the flexor short of the first toe, suturing it to the tendon-muscular part in the position of plantar flexion of the finger

The size of the tendon flap of the abductor is determined individually for each patient in order to ensure the necessary plantoflexion of the finger and subsequent reliable and stable fixation in the position of the required correction.

The method is carried out as follows.

A skin incision is made along the medial surface of the metatarsus of the phalangeal joint and the site of attachment of the adductor tendon is isolated (Fig. 1).

Isolation of the tendon part of the abductor (Fig. 2).

Subsequently, the proximal end of the tendon is dissected longitudinally (Fig. 3).

A split graft is formed, and the size of the excised tissues is determined in such a way as to ensure the plantoflexion of the finger (Fig. 4)

Carrying out through the muscle part of the tendons of the long short flexors of the first toe, hemming the end in the position of plantar flexion of the finger, eliminating the extension deformation (Fig. 5).

Thus, the proposed method allows for reliable elimination of the extension of the first finger without the use of joint destructive operations and the use of expensive fixators.

The proposed method makes it possible to visually control the fixation point of the tendon flap of the abductor and the required position of the finger, due to the formation of a split flap from the tendon part of the abductor and its further passage through the muscular part of the short flexors of the first finger, followed by fixation to them. Tensioning the abductor tendon flap eliminates extension deformity. In addition, during the operation, radical osteotomies and arthrodesis of joints are not performed, and there is no need to use expensive fixators.

Prevention of recurrence of deformity is ensured by the stable position of the nail and middle phalanges of the first toe, firmly fixed with the abductor tendon. This method allows for early loading on the operated limb, preserves the pushing function of the first toe, and ensures the preservation of the statodynamic function.

Clinical example:

Patient E., diagnosis: complex static deformity of the right foot. Hallux valgus of 1 toe of the right foot of grade 3. Excess length Ml. Complaints about dysfunction of walking and support, pain in the area of 1 toe along the inner surface of the 1 metatarsophalangeal joint, pain in the area of the plantar zone 2, 3 toes, deformity of 1 and 2 toes of the right foot.

After preliminary preparation, surgical treatment was performed

Reconstruction of the forefoot of the right foot. SCARF osteotomies with shortening of excess length Ml. Akin osteotomy, Weil 2, 3 metatarsals. The shortening of Ml resulted in iatrogenic extension of 1 toe. The further course of the operation was changed. Access to the tendon sheath of the abductor tendon was made from the existing incision. The sheath of the abductor tendon is exposed. The tenotomy area is marked. The tendon is sutured at the level of the mark, the proximal end is cut off to form a split flap and held onto the handles. Further, the muscle part of the long and short flexors of the fingers is diluted and the split end of the abductor tendon is carried out and its further suturing to the muscle-tendon part of the short flexor of 1 finger with interrupted sutures.

From the 1st day, the load was allowed in special shoes with a changed center of gravity (Baruk's shoes). Walking in regular shoes is allowed 6 weeks after the operation.

At the follow-up examination carried out after 8 weeks, an excellent cosmetic and functional result was noted.

No recurrence of deformity was noted.

Surgical intervention by the proposed method was performed on 6 feet in 6 patients. The results were assessed using the American Foot and Ankle Association Scale (AOFAS) for each foot individually. The average preoperative indicator on the AOFAS scale was 27.1 points, the postoperative indicator was 90.7 points. The average increase in ratings was 63.6 points. Good treatment results were observed in 88.7% of the operated patients.

Claims (1)

A method of surgical correction of iatrogenic extension of the first toe, in which a skin incision is made along the medial surface of the metatarsophalangeal joint, the attachment site of the abductor tendon is isolated, then the proximal end of the tendon is dissected longitudinally in the proximal direction to the muscle part, forming a split graft, and the size of the excised tissues is determined in this way in order to ensure the plantoflexion of the toe and its subsequent fixation, after which the formed part of the tendon flap of the abductor is passed through the muscular part of the short and long flexor of the first toe in the plantar direction, followed by fixation to the muscular-tendon part of the short flexor of 1 finger in the position of correction of 1 toe by nodal or continuous seams.

Images